Basic Information
| Provider Information | |||||||||
| NPI: | 1972785558 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMPREHENSIVE FOOT CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5601 NE ANTIOCH RD | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | GLADSTONE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641192302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164551155 | ||||||||
| FaxNumber: | 8164551161 | ||||||||
| Practice Location | |||||||||
| Address1: | 5601 NE ANTIOCH RD | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | GLADSTONE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641192302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164551155 | ||||||||
| FaxNumber: | 8164551161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2007 | ||||||||
| LastUpdateDate: | 12/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | BOLDRY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8164551155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMPREHENSIVE FOOT CENTERS | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.