Provider Demographics
NPI:1548554967
Name:ACTIVE FEET , FOOT & ANKLE HEALTH CLINIC, INC
Entity type:Organization
Organization Name:ACTIVE FEET , FOOT & ANKLE HEALTH CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:612-788-8778
Mailing Address - Street 1:6600 LYNDALE AVE SOUTH
Mailing Address - Street 2:SUITE 130
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-3398
Mailing Address - Country:US
Mailing Address - Phone:612-788-8778
Mailing Address - Fax:612-869-3473
Practice Address - Street 1:11901 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3911
Practice Address - Country:US
Practice Address - Phone:612-788-8778
Practice Address - Fax:612-869-3473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty