Basic Information
| Provider Information | |||||||||
| NPI: | 1790795904 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOT & ANKLE CENTER, LLC | ||||||||
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| OtherOrganizationName: | FOOT & ANKLE CENTER-FAIRVIEW HEIGHTS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1299 REAVIS BARRACKS RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631253260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144879300 | ||||||||
| FaxNumber: | 3144879338 | ||||||||
| Practice Location | |||||||||
| Address1: | 957 LINCOLN HWY | ||||||||
| Address2: | |||||||||
| City: | FAIRVIEW HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622082234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186324885 | ||||||||
| FaxNumber: | 6186320350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 12/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | AQUINO | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3144879300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FOOT & ANKLE CENTER, LLC | ||||||||
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| AuthorizedOfficialCredential: | DPM, FACFAS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016005263 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.