Provider Demographics
NPI:1750686747
Name:ACTIVE FEET LLC
Entity Type:Organization
Organization Name:ACTIVE FEET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:612-240-6028
Mailing Address - Street 1:7250 FRANCE AVE S
Mailing Address - Street 2:SUITE 415
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4305
Mailing Address - Country:US
Mailing Address - Phone:952-926-3566
Mailing Address - Fax:952-929-3358
Practice Address - Street 1:7250 FRANCE AVE S
Practice Address - Street 2:SUITE 415
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4305
Practice Address - Country:US
Practice Address - Phone:952-926-3566
Practice Address - Fax:952-929-3358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN595261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric