Provider Demographics
NPI:1518393941
Name:FEETLABS SC
Entity Type:Organization
Organization Name:FEETLABS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:217-607-1186
Mailing Address - Street 1:1207 S MATTIS AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-4862
Mailing Address - Country:US
Mailing Address - Phone:217-607-1186
Mailing Address - Fax:
Practice Address - Street 1:1207 S MATTIS AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-4862
Practice Address - Country:US
Practice Address - Phone:217-607-1186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005102261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL19321186431Medicaid
IL19321186431Medicaid
ILU86305Medicare UPIN
ILL95314Medicare PIN