Healthcare Provider Details

I. General information

NPI: 1083675458
Provider Name (Legal Business Name): ST CLOUD FOOT & ANKLE CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 DOCTORS PARK
ST CLOUD MN
56303-1207
US

IV. Provider business mailing address

106 DOCTORS PARK
ST CLOUD MN
56303-1207
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-5444
  • Fax: 320-656-9590
Mailing address:
  • Phone: 320-251-5444
  • Fax: 320-656-9590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WALTER NICHOLAS ELLIS
Title or Position: OWNER
Credential: DPM
Phone: 320-251-5444