Healthcare Provider Details

I. General information

NPI: 1255622544
Provider Name (Legal Business Name): COMMONWEALTH FOOT AND ANKLE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2011
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 BROOKHAVEN RD
FRANKLIN KY
42134-2745
US

IV. Provider business mailing address

1945 SCOTTSVILLE RD B-2 PMB 109
BOWLING GREEN KY
42104-3376
US

V. Phone/Fax

Practice location:
  • Phone: 270-598-4910
  • Fax: 270-598-4930
Mailing address:
  • Phone: 270-598-4910
  • Fax: 270-598-4930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number00337
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number00337
License Number StateKY

VIII. Authorized Official

Name: JENNIFER BENGE
Title or Position: OWNER
Credential: DPM
Phone: 270-598-4910