Provider Demographics
NPI:1326236514
Name:SOUTHWEST FAMILY FOOTCARE SPECIALIST, LLC
Entity Type:Organization
Organization Name:SOUTHWEST FAMILY FOOTCARE SPECIALIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:SPEARS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:269-639-1115
Mailing Address - Street 1:PO BOX 2078
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2078
Mailing Address - Country:US
Mailing Address - Phone:269-639-1115
Mailing Address - Fax:269-639-2525
Practice Address - Street 1:10570 BLUE STAR M HWY
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-8923
Practice Address - Country:US
Practice Address - Phone:269-639-1115
Practice Address - Fax:269-639-2525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001629213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty