Organization
GREAT LAKES FOOT & ANKLE CENTERS INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN L BOSTANCHE DPM (PHYSICIAN/OWNER)
(262) 652-3668
Entity
Organization
Contact information
Practice address
6123 GREEN BAY RD, SUITE 100, KENOSHA, WI 53142-2927
(262) 652-3668
(262) 652-0564
Mailing address
6123 GREEN BAY RD, SUITE 100, KENOSHA, WI 53142-2927
(262) 652-3668
(262) 652-0564
Taxonomy
Speciality
Code
Description
License number
State
213ES0103X
Foot & Ankle Surgery Podiatrist
016
IL
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
025
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
43215000
—
WI
05
—
43220100
—
WI
05
—
43237400
—
WI
Enumeration date
05/15/2007
Last updated
09/20/2021
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