Healthcare Provider Details

I. General information

NPI: 1154426484
Provider Name (Legal Business Name): CLINTON FOOT & ANKLE CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1671 W MICHIGAN AVE STE C-1
CLINTON MI
49236-8702
US

IV. Provider business mailing address

PO BOX 0
CLINTON MI
49236-9502
US

V. Phone/Fax

Practice location:
  • Phone: 517-456-4114
  • Fax: 517-456-4114
Mailing address:
  • Phone: 517-456-4114
  • Fax: 517-456-4114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901000792
License Number StateMI

VIII. Authorized Official

Name: CHERI ROSE DEROCHIE
Title or Position: BILLING MANAGER
Credential:
Phone: 620-615-6033