Provider Demographics
NPI:1578568523
Name:PEDORTHIC FOOTCARE SERVICES, LLC
Entity Type:Organization
Organization Name:PEDORTHIC FOOTCARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED PEDORTHIC
Authorized Official - Phone:417-869-0535
Mailing Address - Street 1:1320 W SUNSHINE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-2345
Mailing Address - Country:US
Mailing Address - Phone:417-869-0535
Mailing Address - Fax:417-869-6669
Practice Address - Street 1:1320 W SUNSHINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-2345
Practice Address - Country:US
Practice Address - Phone:417-869-0535
Practice Address - Fax:417-869-6669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5291100001Medicare ID - Type Unspecified