Provider Demographics
NPI:1619301751
Name:COMMUNITY FOOT CLINIC OF MCPHERSON LLC
Entity Type:Organization
Organization Name:COMMUNITY FOOT CLINIC OF MCPHERSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:TIMSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:620-241-3313
Mailing Address - Street 1:316 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MCPHERSON
Mailing Address - State:KS
Mailing Address - Zip Code:67460-2301
Mailing Address - Country:US
Mailing Address - Phone:620-241-3313
Mailing Address - Fax:620-241-6967
Practice Address - Street 1:316 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MCPHERSON
Practice Address - State:KS
Practice Address - Zip Code:67460-2301
Practice Address - Country:US
Practice Address - Phone:620-241-3313
Practice Address - Fax:620-241-6967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12-00301332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100317700AMedicaid
KS100317700AMedicaid
KS1237050001Medicare NSC
KSU70793Medicare PIN