Healthcare Provider Details

I. General information

NPI: 1679987788
Provider Name (Legal Business Name): ELITE FOOT & ANKLE CLINIC SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1779 MAIN ST
GREEN BAY WI
54302-3250
US

IV. Provider business mailing address

1779 MAIN ST
GREEN BAY WI
54302-3250
US

V. Phone/Fax

Practice location:
  • Phone: 920-465-0181
  • Fax: 920-465-3916
Mailing address:
  • Phone: 920-465-0181
  • Fax: 920-465-3916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number1036-25
License Number StateWI

VIII. Authorized Official

Name: MRS. DEBBIE MARY ARBES
Title or Position: MANAGER
Credential: CMA
Phone: 920-465-0181