=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588737183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNEDY FOOT CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 10/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1024 S 6TH ST SUITE 102
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47807-5015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-554-7709
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 888 E CAMBRIDGE DR
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47802-9344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-554-7709
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WENDY KENNEDY
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 317-554-7709
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------