Healthcare Provider Details

I. General information

NPI: 1134162910
Provider Name (Legal Business Name): FOOT & ANKLE CLINIC OF CENTRAL NEBRASKA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N DIERS AVE STE 100
GRAND ISLAND NE
68803-4985
US

IV. Provider business mailing address

PO BOX 5020
GRAND ISLAND NE
68802-5020
US

V. Phone/Fax

Practice location:
  • Phone: 308-381-0404
  • Fax: 308-381-0408
Mailing address:
  • Phone: 308-381-0404
  • Fax: 308-381-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN J LARSEN
Title or Position: PRESIDENT
Credential: DPM
Phone: 308-381-0404