=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467993394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NETTESHEIM FAMILY FOOTCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2017
-----------------------------------------------------
Last Update Date | 03/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4305 BUTLER HILL RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128-3718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-839-9009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4305 BUTLER HILL RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128-3718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RECEPTION
-----------------------------------------------------
Name | BETH CONWAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-839-9009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 000531
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------