Provider Demographics
NPI:1275546962
Name:FOOT & ANKLE CENTER, LLC
Entity Type:Organization
Organization Name:FOOT & ANKLE CENTER, LLC
Other - Org Name:FOOT & ANKLE CENTER-WATERLOO
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:AQUINO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM, FACAS
Authorized Official - Phone:314-487-9300
Mailing Address - Street 1:1299 REAVIS BARRACKS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125-3260
Mailing Address - Country:US
Mailing Address - Phone:314-487-9300
Mailing Address - Fax:314-487-9338
Practice Address - Street 1:509 HAMACHER ST
Practice Address - Street 2:SUITE 202
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-5979
Practice Address - Fax:618-939-5984
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOOT & ANKLE CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-14
Last Update Date:2008-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005263213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4461710009Medicare NSC
IL213138Medicare PIN