Provider Demographics
NPI:1932208915
Name:FAMILY FOOT CARE PC
Entity Type:Organization
Organization Name:FAMILY FOOT CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KETNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-224-3933
Mailing Address - Street 1:2011 ROCK ST
Mailing Address - Street 2:SUITE D1
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354
Mailing Address - Country:US
Mailing Address - Phone:815-224-3933
Mailing Address - Fax:815-224-2768
Practice Address - Street 1:2011 ROCK ST
Practice Address - Street 2:SUITE D1
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354
Practice Address - Country:US
Practice Address - Phone:815-224-3933
Practice Address - Fax:815-224-2768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004241213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
920410Medicare ID - Type Unspecified
IL4806560001Medicare NSC
U19167Medicare UPIN