Provider Demographics
NPI:1194094607
Name:THE FOOT AND ANKLE WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:THE FOOT AND ANKLE WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRI'
Authorized Official - Middle Name:L
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-481-3338
Mailing Address - Street 1:4440 LINCOLN HWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2349
Mailing Address - Country:US
Mailing Address - Phone:708-481-3338
Mailing Address - Fax:708-481-8643
Practice Address - Street 1:4440 LINCOLN HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2349
Practice Address - Country:US
Practice Address - Phone:708-481-3338
Practice Address - Fax:708-481-8643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL316.001386213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty