=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447421904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWEETWATER FOOT CARE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2008
-----------------------------------------------------
Last Update Date | 03/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2631 FOOTHILL BLVD STE C
-----------------------------------------------------
City | ROCK SPRINGS
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82901-4770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-362-9545
-----------------------------------------------------
Fax | 307-362-9732
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2631 FOOTHILL BLVD STE C
-----------------------------------------------------
City | ROCK SPRINGS
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82901-4770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-362-9545
-----------------------------------------------------
Fax | 307-362-9732
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. DAVID A. DUCKWITZ
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 307-362-9545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number | 119
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------