Provider Demographics
NPI:1811318330
Name:NORTH CENTRAL TEXAS FOOT & ANKLE, LLC
Entity type:Organization
Organization Name:NORTH CENTRAL TEXAS FOOT & ANKLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-730-5058
Mailing Address - Street 1:1713 S FM 51
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3642
Mailing Address - Country:US
Mailing Address - Phone:940-627-6976
Mailing Address - Fax:940-627-3491
Practice Address - Street 1:1713 S FM 51
Practice Address - Street 2:SUITE 103
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3642
Practice Address - Country:US
Practice Address - Phone:940-627-6976
Practice Address - Fax:940-627-3491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1932213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0039ZPOtherBCBSTX
TX334277601Medicaid
TX334277601Medicaid