Provider Demographics
NPI:1982723623
Name:CFAC INCORPORATED
Entity Type:Organization
Organization Name:CFAC INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILBERT
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:309-212-3066
Mailing Address - Street 1:9 MACKENZIE CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-7047
Mailing Address - Country:US
Mailing Address - Phone:309-212-3066
Mailing Address - Fax:
Practice Address - Street 1:103 S JOHN ST
Practice Address - Street 2:
Practice Address - City:DWIGHT
Practice Address - State:IL
Practice Address - Zip Code:60420-1413
Practice Address - Country:US
Practice Address - Phone:815-584-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004981213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDF6156Medicare PIN
IL5917100001Medicare NSC
IL212495Medicare PIN
ILIL7583Medicare PIN