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General NPI Number Information
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NPI Number | 1275758351
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Entity Type | Organization
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Legal Business Name | TRI LAKES PODIATRY PC
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Dates
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Enumeration Date | 04/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 105 S RIDGECREST AVE
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City | NIXA
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State | MO
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Zip | 65714-7807
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Country | US
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Telephone | 417-724-3100
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Fax | 417-725-2985
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Provider Business Mailing Address
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Address Line | PO BOX 870 300 WEST MT VERNON SUITE G
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City | NIXA
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State | MO
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Zip | 65714-0870
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Country | US
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Telephone | 417-725-9995
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Fax | 417-725-2985
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Authorized Official
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Title or Position | OWNER DOCTOR
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Name | JEFFREY P KORTE
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Credential | DPM
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Telephone | 417-725-9995
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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 | 2000165040
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License Number State | MO
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