Provider Demographics
NPI:1437136926
Name:PRAIRIE ROCK FOOT & ANKLE CLINIC LTD
Entity Type:Organization
Organization Name:PRAIRIE ROCK FOOT & ANKLE CLINIC LTD
Other - Org Name:MANTENO FOOT & ANKLE CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALENE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LESAGE
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:815-468-7117
Mailing Address - Street 1:2825 WEST DIVISION STREET
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-1518
Mailing Address - Country:US
Mailing Address - Phone:815-468-7117
Mailing Address - Fax:815-468-7510
Practice Address - Street 1:2825 WEST DIVISION STREET
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-1518
Practice Address - Country:US
Practice Address - Phone:815-468-7117
Practice Address - Fax:815-468-7510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203799OtherMEDICARE GROUP NUMBER
IL480034698OtherRAILROAD MEDICARE
IL551940Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL203799OtherMEDICARE GROUP NUMBER
IL480034698OtherRAILROAD MEDICARE