1760762439 NPI number — RED'S SHOE BARN, INC

Table of content: (NPI 1760762439)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760762439 NPI number — RED'S SHOE BARN, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED'S SHOE BARN, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760762439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03820-3217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-742-1893
Provider Business Mailing Address Fax Number:
603-742-9133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 PLAISTOW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLAISTOW
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03865-4802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-382-7688
Provider Business Practice Location Address Fax Number:
603-382-7709
Provider Enumeration Date:
08/25/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CULLEN
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
IT MANAGER
Authorized Official Telephone Number:
16037421893

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)