Healthcare Provider Details

I. General information

NPI: 1457979379
Provider Name (Legal Business Name): FAMILY FOOT AND ANKLE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 ALPINE CT
SHAWANO WI
54166-2048
US

IV. Provider business mailing address

5403 NORMANDY ST
WESTON WI
54476-2217
US

V. Phone/Fax

Practice location:
  • Phone: 715-298-5949
  • Fax:
Mailing address:
  • Phone: 715-241-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOEL J TIKALSKY
Title or Position: PRESIDENT
Credential: DPM
Phone: 715-241-8100