Healthcare Provider Details

I. General information

NPI: 1104004290
Provider Name (Legal Business Name): PERFORMANCE FOOT AND ANKLE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15300 WEST AVE SUITE 210
ORLAND PARK IL
60462-4600
US

IV. Provider business mailing address

401 E 162ND ST SUITE 101
SOUTH HOLLAND IL
60473-2236
US

V. Phone/Fax

Practice location:
  • Phone: 708-873-9440
  • Fax: 708-873-1862
Mailing address:
  • Phone: 708-596-3757
  • Fax: 708-596-3779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016004747
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5000520001
License Number StateIL

VIII. Authorized Official

Name: DR. DALE S BRINK
Title or Position: OWNER
Credential: DPM
Phone: 708-596-3757