Healthcare Provider Details

I. General information

NPI: 1689734873
Provider Name (Legal Business Name): CHIPPEWA VALLEY FOOT AND ANKLE CLINIC SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 SOUTHTOWN DR
EAU CLAIRE WI
54701-2635
US

IV. Provider business mailing address

4212 SOUTHTOWN DR
EAU CLAIRE WI
54701-2635
US

V. Phone/Fax

Practice location:
  • Phone: 715-832-1400
  • Fax: 715-832-4187
Mailing address:
  • Phone: 715-832-1400
  • Fax: 715-832-4187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number848-025
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: ERIC F CAPORUSSO
Title or Position: PRESIDENT
Credential: DPM
Phone: 715-832-1400