Healthcare Provider Details

I. General information

NPI: 1568715241
Provider Name (Legal Business Name): REID A BETTENCOURT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 S RIVERSIDE PLZ STE 19 EAST
CHICAGO IL
60606-3728
US

IV. Provider business mailing address

10 S RIVERSIDE PLZ STE 19 EAST
CHICAGO IL
60606-3728
US

V. Phone/Fax

Practice location:
  • Phone: 773-770-0140
  • Fax: 312-277-6757
Mailing address:
  • Phone: 773-770-0140
  • Fax: 312-277-6757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number203
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: