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General NPI Number Information
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NPI Number | 1912229105
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Entity Type | Organization
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Legal Business Name | EXCEL FOOTCARE
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Dates
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Enumeration Date | 02/16/2010
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Last Update Date | 03/21/2013
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Provider Practice Location Address
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Address Line | 2424 FORDHAM ST
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City | KEEGO HARBOR
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State | MI
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Zip | 48320-1412
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Country | US
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Telephone | 313-384-7300
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Fax | 248-747-4014
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Provider Business Mailing Address
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Address Line | 2424 FORDHAM ST
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City | KEEGO HARBOR
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State | MI
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Zip | 48320-1412
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Country | US
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Telephone | 313-384-7300
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Fax | 248-747-4014
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Authorized Official
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Title or Position | CEO
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Name | DR. CHANTALE E BOTHUELL
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Credential | D.P.M.
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Telephone | 313-384-7300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 5901002140
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License Number State | MI
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