1326236514 NPI number — SOUTHWEST FAMILY FOOTCARE SPECIALIST, LLC

Table of content: (NPI 1326236514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326236514 NPI number — SOUTHWEST FAMILY FOOTCARE SPECIALIST, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST FAMILY FOOTCARE SPECIALIST, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326236514
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2078
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49081-2078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-639-1115
Provider Business Mailing Address Fax Number:
269-639-2525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10570 BLUE STAR M HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH HAVEN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49090-8923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-639-1115
Provider Business Practice Location Address Fax Number:
269-639-2525
Provider Enumeration Date:
10/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SPEARS
Authorized Official First Name:
REGINA
Authorized Official Middle Name:
LYNNE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
269-639-1115

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  5901001629 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com