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General NPI Number Information
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NPI Number | 1124286927
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Entity Type | Organization
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Legal Business Name | FOOTCO ORTHOPEDIC
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Dates
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Enumeration Date | 05/28/2008
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Last Update Date | 05/28/2008
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Provider Practice Location Address
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Address Line | 3723 N SOUTHPORT AVE
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City | CHICAGO
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State | IL
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Zip | 60613-3718
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Country | US
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Telephone | 312-409-2175
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 13377
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City | CHICAGO
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State | IL
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Zip | 60613-0377
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR, CHIEF CLINICIAN
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Name | TIM PORCELLI
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Credential | LC PED
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Telephone | 312-409-2175
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number | 212.000115
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License Number State | IL
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