Healthcare Provider Details

I. General information

NPI: 1649387424
Provider Name (Legal Business Name): FOOT AND ANKLE CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 PIERCE ST
SIOUX CITY IA
51105-1246
US

IV. Provider business mailing address

1502 PIERCE ST
SIOUX CITY IA
51105-1246
US

V. Phone/Fax

Practice location:
  • Phone: 712-255-0502
  • Fax: 712-258-9977
Mailing address:
  • Phone: 712-255-0502
  • Fax: 712-258-9977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number00505
License Number StateIA

VIII. Authorized Official

Name: DR. KHAM VAY UNG
Title or Position: PRESIDENT/OWNER
Credential: DPM
Phone: 712-255-0502