1467577981 NPI number — FOOT AND ANKLE WELLNESS CENTER

Table of content: (NPI 1467577981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467577981 NPI number — FOOT AND ANKLE WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT AND ANKLE WELLNESS 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:
Provider Other Organization Name Type Code:
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:
1467577981
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3540 SEVEN BRIDGES DR
Provider Second Line Business Mailing Address:
SUITE 290
Provider Business Mailing Address City Name:
WOODRIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60517-1221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-852-8522
Provider Business Mailing Address Fax Number:
630-541-2214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3540 SEVEN BRIDGES DR
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
WOODRIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60517-1221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-852-8522
Provider Business Practice Location Address Fax Number:
630-541-2214
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VEKKOS
Authorized Official First Name:
LEONARD
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
630-852-8522

Provider Taxonomy Codes

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

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

  • Identifier: 4910850002 . This is a "DMERC NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 4910850001 . This is a "DMERC NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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