Provider Demographics
NPI:1649453887
Name:COMPLETE FOOT AND ANKLE CENTER, LLC
Entity type:Organization
Organization Name:COMPLETE FOOT AND ANKLE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINCOLN
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:NOWLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:660-429-2626
Mailing Address - Street 1:521 E YOUNG AVE
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-1228
Mailing Address - Country:US
Mailing Address - Phone:660-429-2626
Mailing Address - Fax:660-429-3356
Practice Address - Street 1:521 E YOUNG AVE
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-1228
Practice Address - Country:US
Practice Address - Phone:660-429-2626
Practice Address - Fax:660-429-3356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO000757213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6358420001Medicare NSC
MOMA2194Medicare PIN
MO4332810001Medicare NSC