Provider Demographics
NPI:1235132861
Name:NORTHERN KENTUCKY FAMILY FOOT CARE INC
Entity Type:Organization
Organization Name:NORTHERN KENTUCKY FAMILY FOOT CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:859-635-6666
Mailing Address - Street 1:6200 PLEASANT AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4671
Mailing Address - Country:US
Mailing Address - Phone:513-829-9333
Mailing Address - Fax:
Practice Address - Street 1:7579 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:KY
Practice Address - Zip Code:41001-1041
Practice Address - Country:US
Practice Address - Phone:859-635-6666
Practice Address - Fax:859-635-6607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY239213E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90003716OtherMEDICAID DME
KY7100159900Medicaid
KY6501Medicare PIN
KY90003716OtherMEDICAID DME
KY1272210001Medicare NSC