Basic Information
| Provider Information | |||||||||
| NPI: | 1104099746 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMPREHENSIVE FOOT CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 RUSH CREEK PKWY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640689604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164551155 | ||||||||
| FaxNumber: | 8164551161 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 PROGRESS DR | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | LANSING | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660436326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164551155 | ||||||||
| FaxNumber: | 8164551161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2008 | ||||||||
| LastUpdateDate: | 04/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | BOLDRY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8164551155 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 12-00227 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.