Provider Demographics
NPI:1316077209
Name:MISSOURI FOOT CARE CENTERS, INC
Entity type:Organization
Organization Name:MISSOURI FOOT CARE CENTERS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:JEANE
Authorized Official - Last Name:RUDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-532-3131
Mailing Address - Street 1:1705 CHRISTY DR
Mailing Address - Street 2:SUITE 209
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5195
Mailing Address - Country:US
Mailing Address - Phone:573-634-3338
Mailing Address - Fax:573-634-3985
Practice Address - Street 1:1705 CHRISTY DR.
Practice Address - Street 2:SUITE 209
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5195
Practice Address - Country:US
Practice Address - Phone:573-634-3338
Practice Address - Fax:573-634-3985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000552213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504901505Medicaid
MO364901504Medicaid
MO30257410Medicaid
MO364901504Medicaid
MOT81014Medicare UPIN
MO30257410Medicaid
MOU89867Medicare UPIN
MO504901505Medicaid