Healthcare Provider Details

I. General information

NPI: 1427464726
Provider Name (Legal Business Name): ACTIVE FOOT AND ANKLE CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 JOHNSTOWN RD
CHESAPEAKE VA
23322-5309
US

IV. Provider business mailing address

369 JOHNSTOWN RD
CHESAPEAKE VA
23322-5309
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-0123
  • Fax: 757-547-2412
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 Number0103301108
License Number StateVA

VIII. Authorized Official

Name: DR. MUNJED SALEM
Title or Position: PRESIDENT
Credential: DPM
Phone: 757-547-0123