Organization
MODERN PODIATRY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KIBIBI WANZU DPM (OWNER)
(470) 781-5585
Entity
Organization
Contact information
Practice address
366 RACETRACK RD, MCDONOUGH, GA 30252-1022
(470) 781-5585
Mailing address
1270 HIGHWAY 314, FAYETTEVILLE, GA 30214-5449
(813) 300-4449
Taxonomy
Speciality
Code
Description
License number
State
261QP1100X
Podiatric Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003233587A
—
GA
Enumeration date
10/04/2019
Last updated
05/13/2024
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