Healthcare Provider Details

I. General information

NPI: 1336310341
Provider Name (Legal Business Name): FAMILY FOOT CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 BUTLER ST STE A
MACON MO
63552-1629
US

IV. Provider business mailing address

PO BOX 447
MACON MO
63552-0447
US

V. Phone/Fax

Practice location:
  • Phone: 660-385-4464
  • Fax: 660-385-1449
Mailing address:
  • Phone: 660-385-4464
  • Fax: 660-385-1449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: KATHY BEAUCHAMP
Title or Position: OFFICE MANAGER
Credential:
Phone: 660-385-4464