Provider Demographics
NPI:1538243076
Name:ACTIVE FOOT & ANKLE CARE, LLC
Entity type:Organization
Organization Name:ACTIVE FOOT & ANKLE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:BRAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-791-1881
Mailing Address - Street 1:4-14 SADDLE RIVER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-5632
Mailing Address - Country:US
Mailing Address - Phone:201-791-1881
Mailing Address - Fax:201-791-6177
Practice Address - Street 1:4-14 SADDLE RIVER RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-5632
Practice Address - Country:US
Practice Address - Phone:201-791-1881
Practice Address - Fax:201-791-6177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00166400213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ057470Medicare PIN
NJ0532820001Medicare NSC