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General NPI Number Information
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NPI Number | 1568655488
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Entity Type | Organization
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Legal Business Name | MUSKOGEE FOOT CLINIC INC.
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Dates
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Enumeration Date | 08/23/2007
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Last Update Date | 06/18/2010
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Provider Practice Location Address
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Address Line | 2400 W BROADWAY ST
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City | MUSKOGEE
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State | OK
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Zip | 74401-2763
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Country | US
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Telephone | 918-687-5171
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Fax | 918-687-7150
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Provider Business Mailing Address
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Address Line | 2400 W BROADWAY ST
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City | MUSKOGEE
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State | OK
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Zip | 74401-2763
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Country | US
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Telephone | 918-687-5171
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Fax | 918-687-7150
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Authorized Official
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Title or Position | PODIATRIST
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Name | DR. DAVID LACY GREEN
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Credential | D.P.M.
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Telephone | 918-687-5171
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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 |
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