1144205766 NPI number — SHOES ETC LLC

Table of content: (NPI 1144205766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144205766 NPI number — SHOES ETC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHOES ETC LLC
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:
6
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:
1144205766
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2652
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRMO
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29063-4003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-781-5757
Provider Business Mailing Address Fax Number:
866-843-2602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7229 SAINT ANDREWS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29212-1178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-781-5757
Provider Business Practice Location Address Fax Number:
888-341-1583
Provider Enumeration Date:
12/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MCLEOD
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-781-5757

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  10400 BCP ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 032383439 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DE2667 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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