Healthcare Provider Details

I. General information

NPI: 1811063274
Provider Name (Legal Business Name): FAMILY FOOT AND ANKLE CENTER, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 E LONGVIEW DR SUITE A
APPLETON WI
54911-2166
US

IV. Provider business mailing address

436 E LONGVIEW DR SUITE A
APPLETON WI
54911-2166
US

V. Phone/Fax

Practice location:
  • Phone: 920-733-5345
  • Fax: 920-733-1390
Mailing address:
  • Phone: 920-733-5345
  • Fax: 920-733-1390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number877
License Number StateWI

VIII. Authorized Official

Name: DR. DIRK SAUL HALVERSON
Title or Position: PRESIDENT
Credential: DPM
Phone: 920-733-5345