1639137755 NPI number — SHOE AND FOOT INC

Table of content: (NPI 1639137755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639137755 NPI number — SHOE AND FOOT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHOE AND FOOT 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:
BOND SHOES AND PEDORTHICS
Provider Other Organization Name Type Code:
3
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:
1639137755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MAPLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONEHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02180-3143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-933-0602
Provider Business Mailing Address Fax Number:
781-497-2926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STONEHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02180-3143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-933-0602
Provider Business Practice Location Address Fax Number:
781-497-2926
Provider Enumeration Date:
05/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOZOVIC
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
781-933-0602

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 800466 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 281754 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 702226 . This is a "HARVARD PILGRIM HC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1538837 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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