Provider Demographics
NPI:1952440273
Name:FIVE LAKES FAMILY FOOT CARE PLLC
Entity Type:Organization
Organization Name:FIVE LAKES FAMILY FOOT CARE PLLC
Other - Org Name:FIVE LAKES IN HOME FOOT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLANNE
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:BRATTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:810-630-8141
Mailing Address - Street 1:2109 CARANOME DR
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-9719
Mailing Address - Country:US
Mailing Address - Phone:810-630-8141
Mailing Address - Fax:810-635-9357
Practice Address - Street 1:2109 CARANOME DR
Practice Address - Street 2:
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-9719
Practice Address - Country:US
Practice Address - Phone:810-630-8141
Practice Address - Fax:810-635-9357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002061213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4412852Medicaid
MI5174610001Medicare NSC
MI0N51140Medicare ID - Type Unspecified
MI4412852Medicaid