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General NPI Number Information
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NPI Number | 1104279561
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Entity Type | Organization
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Legal Business Name | ADVANCED FOOT AND ANKLE CENTER OF KENOSHA S.C.
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Dates
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Enumeration Date | 07/20/2016
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Last Update Date | 07/20/2016
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Provider Practice Location Address
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Address Line | 2901 35TH ST LOWER LEVEL SOUTH
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City | KENOSHA
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State | WI
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Zip | 53140-5117
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Country | US
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Telephone | 262-652-6555
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Fax |
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Provider Business Mailing Address
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Address Line | 2901 35TH ST LOWER LEVEL SOUTH
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City | KENOSHA
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State | WI
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Zip | 53140-5117
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Country | US
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Telephone | 262-652-6555
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DANA DEROUIN
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Credential | DPM
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Telephone | 262-652-6555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 1029-25
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License Number State | WI
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