Provider Demographics
NPI:1104004290
Name:PERFORMANCE FOOT AND ANKLE CENTER LLC
Entity Type:Organization
Organization Name:PERFORMANCE FOOT AND ANKLE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRINK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-596-3757
Mailing Address - Street 1:401 E 162ND ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2236
Mailing Address - Country:US
Mailing Address - Phone:708-596-3757
Mailing Address - Fax:708-596-3779
Practice Address - Street 1:15300 WEST AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4600
Practice Address - Country:US
Practice Address - Phone:708-873-9440
Practice Address - Fax:708-873-1862
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERFORMANCE FOOT AND ANKLE CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-31
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004747213E00000X
IL5000520001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5000520001Medicare NSC
207792Medicare PIN