Provider Demographics
NPI:1942427026
Name:FOOT & ANKLE CENTER, LLC
Entity Type:Organization
Organization Name:FOOT & ANKLE CENTER, LLC
Other - Org Name:FOOT & ANKLE CENTER FAIRVIEW HEIGHTS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:AQUINO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:618-632-4885
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:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:5400 N ILLINOIS ST
Practice Address - Street 2:STE 101
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-3501
Practice Address - Country:US
Practice Address - Phone:618-632-4885
Practice Address - Fax:618-632-0350
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOOT & ANKLE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-19
Last Update Date:2008-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213138Medicare PIN
IL4461710008Medicare NSC