Provider Demographics
NPI:1316013667
Name:THE FOOT PERFORMANCE CENTER, INC.
Entity Type:Organization
Organization Name:THE FOOT PERFORMANCE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDILLO
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:585-473-5950
Mailing Address - Street 1:3385 BRIGHTON HENRIETTA TOWN LINE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-2813
Mailing Address - Country:US
Mailing Address - Phone:585-473-5950
Mailing Address - Fax:585-473-9596
Practice Address - Street 1:3385 BRIGHTON HENRIETTA TOWN LINE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2813
Practice Address - Country:US
Practice Address - Phone:585-473-5950
Practice Address - Fax:585-473-9596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332B00000X
NYNOT REQUIRED335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1316013667OtherEXCELLUS
NY02350998Medicaid
NY106985GDOtherPREFERRED CARE PROV ID
NY106985GDOtherPREFERRED CARE PROV ID