Provider Demographics
NPI:1215041884
Name:NATIONAL PEDORTHIC SERVICES, INC.
Entity Type:Organization
Organization Name:NATIONAL PEDORTHIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:JANISSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-438-1216
Mailing Address - Street 1:7283 W APPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1932
Mailing Address - Country:US
Mailing Address - Phone:414-438-1216
Mailing Address - Fax:414-438-1051
Practice Address - Street 1:727 N NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6715
Practice Address - Country:US
Practice Address - Phone:314-983-9453
Practice Address - Fax:314-983-9457
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NATIONAL PEDORTHIC SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-19
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO623894300Medicaid
MO0461190005Medicare NSC