Healthcare Provider Details

I. General information

NPI: 1700167244
Provider Name (Legal Business Name): MIDWEST FOOT AND ANKLE SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S 4TH ST
LE SUEUR MN
56058-2203
US

IV. Provider business mailing address

621 S 4TH ST
LE SUEUR MN
56058-2203
US

V. Phone/Fax

Practice location:
  • Phone: 507-665-3375
  • Fax:
Mailing address:
  • Phone: 507-665-3375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM NICHOLS
Title or Position: OWNER
Credential: DPM
Phone: 952-890-4061