Form 15 Government Administrative

the

DataBank

DCN: 5950000090960767
Process Date: 12/03/2014
Page: 1
of
3
MANN, ANITTA
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

MANN, ANITTA
LICENSING BOARD
GOVERNMENT ADMINISTRATIVE ACTION

Date of Action: 12/03/2014

Initial Action
- TERMINATION OF MEDICARE OR OTHER FEDERAL
HEALTH CARE PROGRAM PARTICIPATION
- CIVIL MONEY PENALTY IMPOSED BY A FEDERAL OR
STATE HEALTH CARE PROGRAM
A. REPORTING
ENTITY

Entity Name:
Address:
City, State, Zip:
Country:
Name or Office:
Title or Department:
Telephone:
Entity Internal Report Reference:
Type of Report:

Subject Name:
Other Name(s) Used:
Gender:
Date of Birth:
Organization Name:
Work Address:
City, State, ZIP:
Organization Type:
Home Address:
City, State, ZIP:
Deceased:
Federal Employer Identification Numbers (FEIN):
Social Security Numbers (SSN):
Individual Taxpayer Identification Numbers (ITIN):
National Provider Identifiers (NPI):
Professional School(s) & Year(s) of Graduation:
Occupation/Field of Licensure (Code):
State License Number, State of Licensure:
Drug Enforcement Administration (DEA) Numbers:
Unique Physician Identification Numbers (UPIN):
Name(s) of Health Care Entity (Entities) With Which Subject Is
Affiliated or Associated (Inclusion Does Not Imply Complicity in
the Reported Action.):
Business Address of Affiliate:
City, State, ZIP:
Nature of Relationship(s):

B. SUBJECT
IDENTIFICATION
INFORMATION
(INDIVIDUAL)

Basis for Initial Action
- CLINICAL PRIVILEGES RESTRICTED, SUSPENDED OR
REVOKED BY ANOTHER HOSPITAL OR HEALTH CARE
FACILITY

LICENSING BOARD
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
JANET DOE
BOARD OFFICIAL
(555) 555-5555
INITIAL
MANN, ANITTA
FEMALE
01/01/1982
LICENSING BOARD
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
CHIROPRACTIC GROUP/PRACTICE (361)
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
NO
***-**-1111

UNIVERSITY OF THE FOOT (2006)
PODIATRIST
SL56, MD
AM111111111

FOOTCAREINC

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960767
Process Date: 12/03/2014
Page: 2
of
3
MANN, ANITTA
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

Type of Adverse Action: GOVERNMENT ADMINISTRATIVE
Basis for Action: CLINICAL PRIVILEGES RESTRICTED, SUSPENDED OR REVOKED BY
ANOTHER HOSPITAL OR HEALTH CARE FACILITY (A8)
Name of Agency or Program
That Took the Adverse Action
Specified in This Report: ABCD
Adverse Action
Classification Code(s): TERMINATION OF MEDICARE OR OTHER FEDERAL HEALTH CARE
PROGRAM PARTICIPATION (1510)
CIVIL MONEY PENALTY IMPOSED BY A FEDERAL OR STATE HEALTH
CARE PROGRAM (1531)
Date Action Was Taken: 12/03/2014
Date Action Became Effective: 12/03/2014
Length of Action: PERMANENT
Total Amount of Monetary Penalty,
Assessment and/or Restitution: $ 1.00
Is Subject Automatically Reinstated After
Adverse Action Period Is Completed?: YES
Description of Subject's Act(s) or Omission(s) or Other
Reasons for Action(s) Taken and Description of Action(s) Taken
by Reporting Entity: PROVIDED BAD FOOT CARE.

C. INFORMATION
REPORTED

X

Subject identified in Section B has appealed the reported adverse action.
Date of Appeal: 12/03/2014

D. SUBJECT
STATEMENT

If the subject identified in Section B of this report has submitted a statement, it appears in this section.

E. REPORT STATUS

Unless a box below is checked, the subject of this report identified in Section B has not contested this report.
This report has been disputed by the subject identified in Section B.
At the request of the subject identified in Section B, this report is being reviewed by the Secretary of the
U.S. Department of Health and Human Services to determine its accuracy and/or whether it complies with
reporting requirements. No decision has been reached.
At the request of the subject identified in Section B, this report was reviewed by the Secretary of the U.S.
Department of Health and Human Services and a decision was reached. The subject has requested that
the Secretary reconsider the original decision.
At the request of the subject identified in Section B, this report was reviewed by
the Secretary of the U.S. Department of Health and Human Services. The Secretary’s decision
is shown below:
Date of Original Submission:

12/03/2014

Date of Most Recent Change:

12/03/2014

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960767
Process Date: 12/03/2014
Page: 3
of
3
MANN, ANITTA
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

This report is maintained under the provisions of: Section 1921
The information contained in this report is maintained by the National Practitioner Data Bank for restricted use under the
provisions of Section 1921 of the Social Security Act, and 45 CFR Part 60. All information is confidential and may be used only for
the purpose for which it was disclosed. Disclosure or use of confidential information for other purposes is a violation of federal law.
For additional information or clarification, contact the reporting entity identified in Section A.
END OF REPORT

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960768
Process Date: 12/03/2014
Page: 1
of
2
FOOTCAREINC.
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

FOOTCAREINC.
LICENSING BOARD
GOVERNMENT ADMINISTRATIVE ACTION

Date of Action: 12/03/2014

Initial Action
- CONTRACT TERMINATION

A. REPORTING
ENTITY

- DEBARMENT FROM FEDERAL OR STATE PROGRAM

Entity Name:
Address:
City, State, Zip:
Country:
Name or Office:
Title or Department:
Telephone:
Entity Internal Report Reference:
Type of Report:

Organization Name:
Other Organization Name(s) Used:
Business Address:
City, State, ZIP:
Organization Type:
Names and Titles of Principal Officers and Owners (POO):
Federal Employer Identification Numbers (FEIN):
Social Security Numbers (SSN):
Individual Taxpayer Identification Numbers (ITIN):
State License Number, State of Licensure:
Drug Enforcement Administration (DEA) Numbers:
Clinical Laboratory Act (CLIA) Numbers:
Food and Drug Administration (FDA) Numbers:
National Provider Identifiers (NPI):
Medicare Provider/Supplier Numbers:
Name(s) of Health Care Entity (Entities) With Which Subject Is
Affiliated or Associated (Inclusion Does Not Imply Complicity in
the Reported Action.):
Business Address of Affiliate:
City, State, ZIP:
Nature of Relationship(s):

B. SUBJECT
IDENTIFICATION
INFORMATION
(ORGANIZATION)

C. INFORMATION
REPORTED

Basis for Initial Action

Type of Adverse Action:
Basis for Action:
Name of Agency or Program
That Took the Adverse Action
Specified in This Report:
Adverse Action
Classification Code(s):
Date Action Was Taken:
Date Action Became Effective:
Length of Action:

LICENSING BOARD
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
JANET DOE
BOARD OFFICIAL
(555) 555-5555
INITIAL
FOOTCAREINC.
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
CHIROPRACTIC GROUP/PRACTICE (361)
MANN, ANITTA
111111111

SL89, MD

FOOTCAREINC2

SUBJECT IS SUBSIDIARY OF AFFILIATE OR ASSOCIATE (600)
GOVERNMENT ADMINISTRATIVE
DEBARMENT FROM FEDERAL OR STATE PROGRAM (82)

ABCD
CONTRACT TERMINATION (3521)
12/03/2014
12/03/2014
INDEFINITE

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960768
Process Date: 12/03/2014
Page: 2
of
2
FOOTCAREINC.
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

Total Amount of Monetary Penalty,
Assessment and/or Restitution:
Is Subject Automatically Reinstated After
Adverse Action Period Is Completed?: YES
Description of Subject's Act(s) or Omission(s) or Other
Reasons for Action(s) Taken and Description of Action(s) Taken
by Reporting Entity: PROVIDED BAD FOOT CARE.
X

Subject identified in Section B has appealed the reported adverse action.
Date of Appeal: 12/03/2014

D. SUBJECT
STATEMENT

If the subject identified in Section B of this report has submitted a statement, it appears in this section.

E. REPORT STATUS

Unless a box below is checked, the subject of this report identified in Section B has not contested this report.
This report has been disputed by the subject identified in Section B.
At the request of the subject identified in Section B, this report is being reviewed by the Secretary of the
U.S. Department of Health and Human Services to determine its accuracy and/or whether it complies with
reporting requirements. No decision has been reached.
At the request of the subject identified in Section B, this report was reviewed by the Secretary of the U.S.
Department of Health and Human Services and a decision was reached. The subject has requested that
the Secretary reconsider the original decision.
At the request of the subject identified in Section B, this report was reviewed by
the Secretary of the U.S. Department of Health and Human Services. The Secretary’s decision
is shown below:
Date of Original Submission:

12/03/2014

Date of Most Recent Change:

12/03/2014

This report is maintained under the provisions of: Section 1921
The information contained in this report is maintained by the National Practitioner Data Bank for restricted use under the
provisions of Section 1921 of the Social Security Act, and 45 CFR Part 60. All information is confidential and may be used only for
the purpose for which it was disclosed. Disclosure or use of confidential information for other purposes is a violation of federal law.
For additional information or clarification, contact the reporting entity identified in Section A.
END OF REPORT

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY