Healthcare Provider Details

I. General information

NPI: 1336309970
Provider Name (Legal Business Name): FOOTWORKS ORTHOTICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W314S2556 PENNY LN
WALES WI
53183-9671
US

IV. Provider business mailing address

W314S2556 PENNY LN
WALES WI
53183-9671
US

V. Phone/Fax

Practice location:
  • Phone: 262-968-3643
  • Fax:
Mailing address:
  • Phone: 262-968-3643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: KYLE ROBERTS
Title or Position: PRESIDENT
Credential: C. PED.
Phone: 262-968-3643