Healthcare Provider Details

I. General information

NPI: 1114991387
Provider Name (Legal Business Name): ADVANCED ANKLE & FOOT CARE CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 BROM DRIVE SUITE 201
NAPERVILLE IL
60540-6054
US

IV. Provider business mailing address

PO BOX 577577
CHICAGO IL
60657-7577
US

V. Phone/Fax

Practice location:
  • Phone: 630-478-3338
  • Fax: 630-355-3016
Mailing address:
  • Phone: 630-478-3338
  • Fax: 630-355-3016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAWRENCE M KOSOVA
Title or Position: PRESIDENT
Credential:
Phone: 630-478-3338