Healthcare Provider Details

I. General information

NPI: 1578568523
Provider Name (Legal Business Name): PEDORTHIC FOOTCARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 W SUNSHINE ST
SPRINGFIELD MO
65807-2345
US

IV. Provider business mailing address

1320 W SUNSHINE ST
SPRINGFIELD MO
65807-2345
US

V. Phone/Fax

Practice location:
  • Phone: 417-869-0535
  • Fax: 417-869-6669
Mailing address:
  • Phone: 417-869-0535
  • Fax: 417-869-6669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. LEE A HUNTER
Title or Position: MANAGING MEMBER/OWNER
Credential: CERTIFIED PEDORTHIC
Phone: 417-869-0535