Healthcare Provider Details

I. General information

NPI: 1295133627
Provider Name (Legal Business Name): COMPLETE FOOT AND ANKLE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2014
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 COMMERCE ST
WELLSBURG WV
26070-1323
US

IV. Provider business mailing address

1512 COMMERCE ST
WELLSBURG WV
26070-1323
US

V. Phone/Fax

Practice location:
  • Phone: 304-737-2964
  • Fax: 304-737-4822
Mailing address:
  • Phone: 740-282-0861
  • Fax: 304-737-2964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number00376
License Number StateWV

VIII. Authorized Official

Name: DEANNE PETRAS
Title or Position: CREDENTIALING
Credential:
Phone: 304-737-7016