Basic Information
| Provider Information | |||||||||
| NPI: | 1164682233 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAPIDS FOOT CARE CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 8TH ST SO | ||||||||
| Address2: | |||||||||
| City: | WISCONSIN RAPIDS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544944622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154238637 | ||||||||
| FaxNumber: | 7154242724 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 8TH ST SO | ||||||||
| Address2: | |||||||||
| City: | WISCONSIN RAPIDS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544944622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154238637 | ||||||||
| FaxNumber: | 7154242724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2008 | ||||||||
| LastUpdateDate: | 11/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | HARDIMAN | ||||||||
| AuthorizedOfficialFirstName: | PATRIC | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7154238637 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 678-025 | WI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 41737500 | 05 | WI | MEDICAID | 43268800 | 05 | WI | MEDICAID |