Healthcare Provider Details

I. General information

NPI: 1346510500
Provider Name (Legal Business Name): MICHIANA FOOT CARE CLINIC L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 E JEFFERSON BLVD
SOUTH BEND IN
46617-2902
US

IV. Provider business mailing address

723 E JEFFERSON BLVD
SOUTH BEND IN
46617-2902
US

V. Phone/Fax

Practice location:
  • Phone: 708-738-2778
  • Fax:
Mailing address:
  • Phone: 708-738-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001107A
License Number StateIN

VIII. Authorized Official

Name: ANTHONY COLE
Title or Position: MEMBER
Credential: D.P.M
Phone: 708-738-2778