Basic Information
| Provider Information | |||||||||
| NPI: | 1770714099 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY FOOT HEALTHCARE, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 927 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507022801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192336107 | ||||||||
| FaxNumber: | 3192339138 | ||||||||
| Practice Location | |||||||||
| Address1: | 502 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506652063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193462331 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2009 | ||||||||
| LastUpdateDate: | 10/01/2009 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3192336107 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 00449 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1710064290 | 05 | IA | MEDICAID |