1770625857 NPI number — ACTIVE FEET, INC.

Table of content: (NPI 1770625857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770625857 NPI number — ACTIVE FEET, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTIVE FEET, INC.
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:
THE ACTIVE FOOT STORE
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:
1770625857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 LOMAS SANTA FE DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
SOLANA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92075-1343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-792-1142
Provider Business Mailing Address Fax Number:
858-755-6785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4545 LA JOLLA VILLAGE DR
Provider Second Line Business Practice Location Address:
#9026
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92122-1241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-453-5057
Provider Business Practice Location Address Fax Number:
858-453-5058
Provider Enumeration Date:
02/13/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
REINGOLD
Authorized Official First Name:
JACK
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-792-1142

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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