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General NPI Number Information
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NPI Number | 1225535867
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Entity Type | Organization
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Legal Business Name | PRAIRIE PODIATRY INC.
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Dates
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Enumeration Date | 04/10/2018
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Last Update Date | 04/10/2018
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Provider Practice Location Address
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Address Line | 21813 CAPPEL LN
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City | FRANKFORT
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State | IL
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Zip | 60423-2275
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Country | US
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Telephone | 978-549-6818
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Fax |
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Provider Business Mailing Address
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Address Line | 21813 CAPPEL LN
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City | FRANKFORT
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State | IL
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Zip | 60423-2275
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Country | US
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Telephone | 978-549-6818
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | WAYNE MCCULLOUGH
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Credential | DPM
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Telephone | 978-549-6818
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213EP1101X
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Taxonomy Name | Primary Podiatric Medicine Podiatrist
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License Number | 0700115A
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License Number State | IN
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