=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215041884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATIONAL PEDORTHIC SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2006
-----------------------------------------------------
Last Update Date | 12/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 727 N NEW BALLAS RD
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-6715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-983-9453
-----------------------------------------------------
Fax | 314-983-9457
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7283 W APPLETON AVE
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53216-1932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-438-1216
-----------------------------------------------------
Fax | 414-438-1051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS MANAGER
-----------------------------------------------------
Name | NICOLE S JANISSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-438-1216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------