=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366539512
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN KENTUCKY FOOT SPECIALISTS, PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2006
-----------------------------------------------------
Last Update Date | 02/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525 ALEXANDRIA PIKE SUITE 230
-----------------------------------------------------
City | SOUTHGATE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41071-3290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-441-4334
-----------------------------------------------------
Fax | 859-441-3698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 389
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41005-0389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-746-7461
-----------------------------------------------------
Fax | 859-746-7464
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WILLIAM M NIELSON
-----------------------------------------------------
Credential | DMP
-----------------------------------------------------
Telephone | 859-746-7461
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------