Provider Demographics
NPI:1164773875
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:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:HOLSOPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
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 1:300 S DORSET RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2635
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:2012-09-21
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003402213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6077150001OtherDMERC