Provider Demographics
NPI:1831761634
Name:MISSOURI VALLEY FOOT & ANKLE CLINIC
Entity type:Organization
Organization Name:MISSOURI VALLEY FOOT & ANKLE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/DPM
Authorized Official - Prefix:
Authorized Official - First Name:FRANCISCO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:TELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:701-751-2641
Mailing Address - Street 1:606 1ST ST NW
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3121
Mailing Address - Country:US
Mailing Address - Phone:701-751-2641
Mailing Address - Fax:
Practice Address - Street 1:606 1ST ST NW
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3121
Practice Address - Country:US
Practice Address - Phone:701-751-2641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-12
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1465351Medicaid