Healthcare Provider Details

I. General information

NPI: 1750686747
Provider Name (Legal Business Name): ACTIVE FEET LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2011
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 FRANCE AVE S SUITE 415
EDINA MN
55435-4305
US

IV. Provider business mailing address

7250 FRANCE AVE S SUITE 415
EDINA MN
55435-4305
US

V. Phone/Fax

Practice location:
  • Phone: 952-926-3566
  • Fax: 952-929-3358
Mailing address:
  • Phone: 952-926-3566
  • Fax: 952-929-3358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number595
License Number StateMN

VIII. Authorized Official

Name: DR. STACEY LEE WHITE
Title or Position: OWNER
Credential: DPM
Phone: 612-240-6028