Basic Information
| Provider Information | |||||||||
| NPI: | 1548260060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNELLGROVE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2290 | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542212290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203202591 | ||||||||
| FaxNumber: | 9203205102 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 S 41ST ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542207316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203205251 | ||||||||
| FaxNumber: | 9206822006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2005 | ||||||||
| LastUpdateDate: | 07/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | PO 3012 | FL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 1428 | WI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.