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General NPI Number Information
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NPI Number | 1861665770
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Entity Type | Organization
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Legal Business Name | ACTIVE FOOT CARE, INC.
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Dates
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Enumeration Date | 04/11/2008
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Last Update Date | 03/07/2013
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Provider Practice Location Address
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Address Line | 2563 HUNTCLIFF LANE
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City | PANAMA CITY
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State | FL
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Zip | 32405-4902
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Country | US
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Telephone | 850-769-1055
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Fax | 850-769-1434
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Provider Business Mailing Address
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Address Line | 2563 HUNTCLIFF LANE
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City | PANAMA CITY
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State | FL
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Zip | 32405-4902
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Country | US
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Telephone | 850-769-1055
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Fax | 850-769-1434
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Authorized Official
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Title or Position | PODIATRIST
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Name | DR. JALAL K SIDANI
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Credential | DPM
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Telephone | 850-769-1055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | P02326
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License Number State | FL
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