Provider Demographics
NPI:1457431942
Name:ST CHARLES FOOT CARE CENTER, TERRY L. GAMACHE, DPM, PC
Entity type:Organization
Organization Name:ST CHARLES FOOT CARE CENTER, TERRY L. GAMACHE, DPM, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GAMACHE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:636-946-9399
Mailing Address - Street 1:110 S KINGSHIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-1636
Mailing Address - Country:US
Mailing Address - Phone:636-946-9399
Mailing Address - Fax:636-946-1972
Practice Address - Street 1:110 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-1636
Practice Address - Country:US
Practice Address - Phone:636-946-9399
Practice Address - Fax:636-946-1972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000344213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCP2258Medicare ID - Type UnspecifiedRAILROAD MEDICARE