Healthcare Provider Details

I. General information

NPI: 1306290648
Provider Name (Legal Business Name): ACTIVE FOOT AND ANKLE OF CAROLINA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1076 US HIGHWAY 17 S
ELIZABETH CITY NC
27909-7627
US

IV. Provider business mailing address

632 CEDAR RD STE B
CHESAPEAKE VA
23322-8376
US

V. Phone/Fax

Practice location:
  • Phone: 252-333-3111
  • Fax: 252-333-1105
Mailing address:
  • Phone: 757-547-0123
  • Fax: 757-547-2412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number623
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number623
License Number StateNC

VIII. Authorized Official

Name: DR. MUNJED SALEM
Title or Position: OWNER
Credential: DPM
Phone: 252-333-3111