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General NPI Number Information
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NPI Number | 1639391907
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Entity Type | Organization
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Legal Business Name | KIRK M BOTT DBA LOGAN AVENUE FOOT CLINIC
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 06/18/2008
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Provider Practice Location Address
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Address Line | 612 N LOGAN AVENUE
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City | DANVILLE
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State | IL
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Zip | 61832
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Country | US
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Telephone | 217-442-4186
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Fax |
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Provider Business Mailing Address
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Address Line | 612 N LOGAN AVENUE
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City | DANVILLE
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State | IL
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Zip | 61832
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Country | US
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Telephone | 217-442-4186
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KIRK M BOTT
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Credential | DPM
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Telephone | 217-442-4186
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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 | 016003907
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License Number State | IL
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