Healthcare Provider Details

I. General information

NPI: 1831761634
Provider Name (Legal Business Name): MISSOURI VALLEY FOOT & ANKLE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 1ST ST NW
MANDAN ND
58554-3121
US

IV. Provider business mailing address

606 1ST ST NW
MANDAN ND
58554-3121
US

V. Phone/Fax

Practice location:
  • Phone: 701-751-2641
  • Fax:
Mailing address:
  • Phone: 701-751-2641
  • Fax:

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: FRANCISCO ANTONIO TELLO
Title or Position: CEO/DPM
Credential: DPM
Phone: 701-751-2641