Basic Information
Provider Information | |||||||||
NPI: | 1760683593 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOES R US, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WAYNEDALE FOOT CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6200 BLUFFTON RD | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468092260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2607475572 | ||||||||
FaxNumber: | 2607478392 | ||||||||
Practice Location | |||||||||
Address1: | 6200 BLUFFTON RD | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468092260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2607475572 | ||||||||
FaxNumber: | 2607478392 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHUBINSKI | ||||||||
AuthorizedOfficialFirstName: | DENNIS | ||||||||
AuthorizedOfficialMiddleName: | JOHN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT OWNER | ||||||||
AuthorizedOfficialTelephone: | 2607475572 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.P.M. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 07000406 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
No ID Information.