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General NPI Number Information
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NPI Number | 1972843613
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Entity Type | Organization
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Legal Business Name | SOUTHERN ILLINOIS FAMILY FOOT CARE, LLC
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Dates
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Enumeration Date | 02/17/2013
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Last Update Date | 05/16/2014
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Provider Practice Location Address
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Address Line | 221 N 27TH ST
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City | MOUNT VERNON
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State | IL
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Zip | 62864-2941
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Country | US
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Telephone | 618-244-3668
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Fax |
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Provider Business Mailing Address
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Address Line | 221 N 27TH ST
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City | MOUNT VERNON
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State | IL
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Zip | 62864-2941
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Country | US
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Telephone | 618-244-3668
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BRIAN LEE
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Credential | D.P.M.
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Telephone | 618-244-3668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 016003846
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License Number State | IL
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