Healthcare Provider Details

I. General information

NPI: 1164773875
Provider Name (Legal Business Name): ACTIVE FOOT AND ANKLE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S DORSET RD
TROY OH
45373-2635
US

IV. Provider business mailing address

300 S DORSET RD
TROY OH
45373-2635
US

V. Phone/Fax

Practice location:
  • Phone: 937-875-2526
  • Fax: 937-459-5433
Mailing address:
  • Phone: 937-875-2526
  • Fax: 937-459-5433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36003402
License Number StateOH

VIII. Authorized Official

Name: WHITNEY RAE HOLSOPPLE
Title or Position: OWNER
Credential: D.P.M
Phone: 937-875-2526