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General NPI Number Information
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NPI Number | 1982789210
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Entity Type | Organization
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Legal Business Name | LAKE COUNTRY FOOT & ANKLE, S.C.
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Dates
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Enumeration Date | 10/26/2006
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Last Update Date | 08/13/2008
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Provider Practice Location Address
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Address Line | 1177 QUAIL CT STE 103
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City | PEWAUKEE
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State | WI
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Zip | 53072-3768
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Country | US
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Telephone | 262-695-6440
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Fax | 262-695-2668
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Provider Business Mailing Address
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Address Line | 1177 QUAIL CT STE 103
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City | PEWAUKEE
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State | WI
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Zip | 53072-3768
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Country | US
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Telephone | 262-695-6440
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Fax | 262-695-2668
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MARY M FOSTER
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Credential |
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Telephone | 262-695-6440
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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 | 794025
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License Number State | WI
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