Provider Demographics
NPI:1861825093
Name:ACTIVE FEET, FOOT & ANKLE HEALTH CENTER
Entity Type:Organization
Organization Name:ACTIVE FEET, FOOT & ANKLE HEALTH CENTER
Other - Org Name:MIDWEST PODIATRY CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR OF PODIATRY
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MOHR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:612-200-8028
Mailing Address - Street 1:6625 LYNDALE AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2491
Mailing Address - Country:US
Mailing Address - Phone:612-200-8028
Mailing Address - Fax:888-231-8658
Practice Address - Street 1:10995 CLUB WEST PKWY STE 300
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5861
Practice Address - Country:US
Practice Address - Phone:612-788-8778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN631261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty