Organization
FOOT CARE STORE INC
Active
Other names
Dia-Foot
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ROBERT MARK GAYNOR DPM (PRESIDENT)
(561) 721-7063
Entity
Organization
Contact information
Practice address
3281 FAIRLANE FARMS RD STE 7, WELLINGTON, FL 33414-6503
(561) 791-1213
(561) 791-9919
Mailing address
3281 FAIRLANE FARMS RD STE 7, WELLINGTON, FL 33414-6503
(561) 791-1213
(561) 791-9919
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
1985
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0008364940
AMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS,PROSTHETICS & PEDORTHICS, INC.
FL
05
—
003177356A
—
GA
05
—
029761501
—
FL
05
—
1740333061
—
VA
Enumeration date
06/29/2010
Last updated
10/07/2016
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