Provider Demographics
NPI:1689612483
Name:CAPTAIN DOC LLC
Entity Type:Organization
Organization Name:CAPTAIN DOC LLC
Other - Org Name:FAMILY FOOT DOCS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KORI
Authorized Official - Middle Name:H
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:816-452-1211
Mailing Address - Street 1:6717 N OAK TRFY
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118-3346
Mailing Address - Country:US
Mailing Address - Phone:816-452-1211
Mailing Address - Fax:816-452-4211
Practice Address - Street 1:6717 N OAK TRFY
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-3346
Practice Address - Country:US
Practice Address - Phone:816-452-1211
Practice Address - Fax:816-452-4211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000701213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4849930001Medicare NSC
MOU53218Medicare UPIN