1841697273 NPI number — ADVANCED FOOT & ANKLE CLINIC LLC

Table of content: (NPI 1841697273)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841697273 NPI number — ADVANCED FOOT & ANKLE CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED FOOT & ANKLE CLINIC LLC
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:
1841697273
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
803 E SCHOOL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWATONNA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55060-3112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-451-5950
Provider Business Mailing Address Fax Number:
507-451-5514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 STATE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRBAULT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-334-1951
Provider Business Practice Location Address Fax Number:
507-451-5514
Provider Enumeration Date:
12/01/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BUTLER
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
ALEXANDER
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
507-451-5950

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 767042700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 28485 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6B282RO . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 114357D102 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".




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