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General NPI Number Information
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NPI Number | 1881872273
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Entity Type | Organization
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Legal Business Name | ACTIVE FOOT AND ANKLE CARE LLC
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Dates
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Enumeration Date | 02/07/2008
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Last Update Date | 12/04/2014
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Provider Practice Location Address
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Address Line | 828 CENTRAL AVE
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City | GREENVILLE
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State | OH
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Zip | 45331-1206
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Country | US
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Telephone | 937-875-2526
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Fax | 937-459-5433
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Provider Business Mailing Address
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Address Line | 300 S DORSET RD
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City | TROY
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State | OH
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Zip | 45373-2635
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Country | US
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Telephone | 937-875-2526
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Fax | 937-459-5433
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | CHAD LIETTE
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Credential |
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Telephone | 937-875-2526
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP1100X
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Taxonomy Name | Podiatric Clinic/Center
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License Number | 36003402
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License Number State | OH
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