Healthcare Provider Details

I. General information

NPI: 1063928752
Provider Name (Legal Business Name): SHEBOYGAN FOOT CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2017
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 RIVERFRONT DR STE 202
SHEBOYGAN WI
53081-4616
US

IV. Provider business mailing address

630 RIVERFRONT DR STE 202
SHEBOYGAN WI
53081-4616
US

V. Phone/Fax

Practice location:
  • Phone: 920-457-6104
  • Fax: 920-457-6105
Mailing address:
  • Phone: 920-457-6104
  • Fax: 920-457-6105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number634-25
License Number StateWI

VIII. Authorized Official

Name: SHEILA WOLFINGTON
Title or Position: BUSINESS MANAGER
Credential:
Phone: 920-457-6104