Provider Demographics
NPI:1881872273
Name:ACTIVE FOOT AND ANKLE CARE LLC
Entity type:Organization
Organization Name:ACTIVE FOOT AND ANKLE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:LIETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-875-2526
Mailing Address - Street 1:300 S DORSET RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2635
Mailing Address - Country:US
Mailing Address - Phone:937-875-2526
Mailing Address - Fax:937-459-5433
Practice Address - Street 1:828 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1206
Practice Address - Country:US
Practice Address - Phone:937-875-2526
Practice Address - Fax:937-459-5433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003402261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2543279Medicaid
OHV04625Medicare UPIN
OH2543279Medicaid
OH6077150001Medicare NSC