1689848392 NPI number — ACTIVE FEET, FOOT & ANKLE HEALTH CENTER

Table of content: (NPI 1689848392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689848392 NPI number — ACTIVE FEET, FOOT & ANKLE HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE FEET, FOOT & ANKLE HEALTH CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MIDWEST PODIATRY CENTERS RICHFIELD
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689848392
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6625 LYNDALE AVE S STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55423-2491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-788-8778
Provider Business Mailing Address Fax Number:
612-869-3473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6625 LYNDALE AVE S STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55423-2673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-788-8778
Provider Business Practice Location Address Fax Number:
612-869-3473
Provider Enumeration Date:
04/15/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOHR
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
612-798-0170

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2134 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: 631 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 335E00000X , with the licence number: 631 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)