1316077209 NPI number — MISSOURI FOOT CARE CENTERS, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316077209 NPI number — MISSOURI FOOT CARE CENTERS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSOURI FOOT CARE CENTERS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316077209
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1705 CHRISTY DR
Provider Second Line Business Mailing Address:
SUITE 209
Provider Business Mailing Address City Name:
JEFFERSON CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65101-5195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-634-3338
Provider Business Mailing Address Fax Number:
573-634-3985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1705 CHRISTY DR.
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65101-5195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-634-3338
Provider Business Practice Location Address Fax Number:
573-634-3985
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RUDDLE
Authorized Official First Name:
KELLI
Authorized Official Middle Name:
JEANE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
636-532-3131

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  000552 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 504901505 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 364901504 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30257410 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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