Healthcare Provider Details

I. General information

NPI: 1811955057
Provider Name (Legal Business Name): COMPREHENSIVE FAMILY FOOT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S MAIN ST
MIDDLETOWN CT
06457-3764
US

IV. Provider business mailing address

210 S MAIN ST
MIDDLETOWN CT
06457-3764
US

V. Phone/Fax

Practice location:
  • Phone: 860-638-4671
  • Fax: 860-638-4673
Mailing address:
  • Phone: 860-638-4671
  • Fax: 860-638-4673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000735
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number000735
License Number StateCT

VIII. Authorized Official

Name: DR. DEBORAH E WATERMAN
Title or Position: DIRECTOR OFFICER
Credential: D.P.M.
Phone: 860-638-4671