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General NPI Number Information
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NPI Number | 1295941409
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Entity Type | Organization
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Legal Business Name | GREAT LAKES FOOT & ANKLE CENTERS INC
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Dates
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Enumeration Date | 05/15/2007
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Last Update Date | 09/20/2021
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Provider Practice Location Address
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Address Line | 6123 GREEN BAY RD SUITE 100
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City | KENOSHA
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State | WI
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Zip | 53142-2927
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Country | US
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Telephone | 262-652-3668
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Fax | 262-652-0564
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Provider Business Mailing Address
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Address Line | 6123 GREEN BAY RD SUITE 100
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City | KENOSHA
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State | WI
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Zip | 53142-2927
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Country | US
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Telephone | 262-652-3668
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Fax | 262-652-0564
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | JOHN L BOSTANCHE
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Credential | DPM
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Telephone | 262-652-3668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 016
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 025
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License Number State | WI
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