1649594870 NPI number — SHOE SPECIALISTS OF LAREDO & MEDICAL SUPPLY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649594870 NPI number — SHOE SPECIALISTS OF LAREDO & MEDICAL SUPPLY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHOE SPECIALISTS OF LAREDO & MEDICAL SUPPLY 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:
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:
1649594870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
517 SHILOH DR
Provider Second Line Business Mailing Address:
STE4
Provider Business Mailing Address City Name:
LAREDO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78045-6722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-508-7666
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
517 SHILOH DR
Provider Second Line Business Practice Location Address:
STE4
Provider Business Practice Location Address City Name:
LAREDO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78045-6722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-508-7666
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ
Authorized Official First Name:
SAN JUANITA
Authorized Official Middle Name:
Authorized Official Title or Position:
SHOE FITTER
Authorized Official Telephone Number:
956-775-7832

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  32021418402 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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