Healthcare Provider Details

I. General information

NPI: 1407994585
Provider Name (Legal Business Name): SUBURBAN FOOT CARE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 04/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 N NEW BALLAS RD SUITE 250
SAINT LOUIS MO
63141-6831
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 314-997-1315
  • Fax: 314-997-2014
Mailing address:
  • Phone: 314-989-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000410
License Number StateMO

VIII. Authorized Official

Name: MARK COMESS
Title or Position: OWNER
Credential: MD
Phone: 314-997-1315