Healthcare Provider Details

I. General information

NPI: 1447421904
Provider Name (Legal Business Name): SWEETWATER FOOT CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 03/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631 FOOTHILL BLVD STE C
ROCK SPRINGS WY
82901-4770
US

IV. Provider business mailing address

2631 FOOTHILL BLVD STE C
ROCK SPRINGS WY
82901-4770
US

V. Phone/Fax

Practice location:
  • Phone: 307-362-9545
  • Fax: 307-362-9732
Mailing address:
  • Phone: 307-362-9545
  • Fax: 307-362-9732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number119
License Number StateWY

VIII. Authorized Official

Name: MR. DAVID A. DUCKWITZ
Title or Position: PRESIDENT
Credential: DPM
Phone: 307-362-9545