Healthcare Provider Details

I. General information

NPI: 1972843613
Provider Name (Legal Business Name): SOUTHERN ILLINOIS FAMILY FOOT CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2013
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 N 27TH ST
MOUNT VERNON IL
62864-2941
US

IV. Provider business mailing address

221 N 27TH ST
MOUNT VERNON IL
62864-2941
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-3668
  • Fax:
Mailing address:
  • Phone: 618-244-3668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number016003846
License Number StateIL

VIII. Authorized Official

Name: DR. BRIAN LEE
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 618-244-3668