Provider Demographics
NPI:1568734044
Name:FAMILY FOOT CLINICS OF WISCONSIN SC
Entity Type:Organization
Organization Name:FAMILY FOOT CLINICS OF WISCONSIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:K
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-637-8806
Mailing Address - Street 1:3535 30TH AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1632
Mailing Address - Country:US
Mailing Address - Phone:262-657-6104
Mailing Address - Fax:262-657-6104
Practice Address - Street 1:5802 WASHINGTON AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4050
Practice Address - Country:US
Practice Address - Phone:262-637-8806
Practice Address - Fax:262-637-2868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty