Provider Demographics
NPI:1508035569
Name:MISSOURI FOOT CARE CENTERS, INC.
Entity Type:Organization
Organization Name:MISSOURI FOOT CARE CENTERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:JEANE
Authorized Official - Last Name:RUDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-270-3060
Mailing Address - Street 1:1705 CHRISTY DR
Mailing Address - Street 2:SUITE 209
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5195
Mailing Address - Country:US
Mailing Address - Phone:573-634-3338
Mailing Address - Fax:
Practice Address - Street 1:1705 CHRISTY DR
Practice Address - Street 2:SUITE 209
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5195
Practice Address - Country:US
Practice Address - Phone:573-634-3338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000552213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504901406Medicaid
MO480025443OtherMEDICARE RAILROAD
MO302574710Medicaid
MOCJ9611OtherMEDICARE RAILROAD
MO000012764Medicare Oscar/Certification
MO302574710Medicaid
MO002012764Medicare Oscar/Certification
MOT81014Medicare UPIN