Healthcare Provider Details

I. General information

NPI: 1093019713
Provider Name (Legal Business Name): FIRST STEP FOOT AND ANKLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 HWY 72 E
ROLLA MO
65401
US

IV. Provider business mailing address

11568 PINE FOREST DR
ROLLA MO
65401-5427
US

V. Phone/Fax

Practice location:
  • Phone: 573-578-0939
  • Fax: 573-426-6051
Mailing address:
  • Phone: 573-578-0939
  • Fax: 573-426-6051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number000803
License Number StateMO

VIII. Authorized Official

Name: CHRISTOPHER L JOHNSON
Title or Position: DOCTOR OF PODIATRIC MEDICINE
Credential: DPM
Phone: 573-578-0939