=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952863235
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTIVE FOOT AND ANKLE CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2019
-----------------------------------------------------
Last Update Date | 04/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 S DORSET RD
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45373-2635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-681-5266
-----------------------------------------------------
Fax | 937-552-9880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11747 FROST RD
-----------------------------------------------------
City | TIPP CITY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45371-9109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-681-5266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WHITNEY R. HOLSOPPLE
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 937-875-2526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------