Provider Demographics
NPI:1811955057
Name:COMPREHENSIVE FAMILY FOOT CENTER LLC
Entity type:Organization
Organization Name:COMPREHENSIVE FAMILY FOOT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:E
Authorized Official - Last Name:WATERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-638-4671
Mailing Address - Street 1:210 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3764
Mailing Address - Country:US
Mailing Address - Phone:860-638-4671
Mailing Address - Fax:860-638-4673
Practice Address - Street 1:210 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3764
Practice Address - Country:US
Practice Address - Phone:860-638-4671
Practice Address - Fax:860-638-4673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000735332B00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4415740003Medicare NSC