Provider Demographics
NPI:1164131306
Name:ACTIVE FOOT SHOES
Entity Type:Organization
Organization Name:ACTIVE FOOT SHOES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAURICIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTU
Authorized Official - Suffix:JR
Authorized Official - Credentials:CEO
Authorized Official - Phone:361-334-0563
Mailing Address - Street 1:5540 SARATOGA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-2953
Mailing Address - Country:US
Mailing Address - Phone:361-334-0563
Mailing Address - Fax:
Practice Address - Street 1:5540 SARATOGA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-2953
Practice Address - Country:US
Practice Address - Phone:361-334-0563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service