Provider Demographics
NPI:1679286132
Name:EASTERN SHORE FAMILY FOOT CARE, LLC
Entity type:Organization
Organization Name:EASTERN SHORE FAMILY FOOT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLI
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-778-1801
Mailing Address - Street 1:6412 CHURCH HILL RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-2386
Mailing Address - Country:US
Mailing Address - Phone:410-778-1801
Mailing Address - Fax:410-758-3249
Practice Address - Street 1:6412 CHURCH HILL RD
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-2386
Practice Address - Country:US
Practice Address - Phone:410-778-1801
Practice Address - Fax:410-758-3249
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN SHORE FAMILY FOOT CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-29
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD870023100Medicaid