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General NPI Number Information
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NPI Number | 1437136926
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Entity Type | Organization
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Legal Business Name | PRAIRIE ROCK FOOT & ANKLE CLINIC LTD
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Dates
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Enumeration Date | 12/27/2005
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2825 WEST DIVISION STREET
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City | MANTENO
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State | IL
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Zip | 60950-1518
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Country | US
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Telephone | 815-468-7117
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Fax | 815-468-7510
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Provider Business Mailing Address
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Address Line | 2825 WEST DIVISION STREET
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City | MANTENO
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State | IL
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Zip | 60950-1518
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Country | US
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Telephone | 815-468-7117
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Fax | 815-468-7510
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. ALENE D LESAGE
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Credential | CMA
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Telephone | 815-468-7117
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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 |
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License Number State | IL
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