1720174675 NPI number — THE SHOE FITS AT 1 FOOT 2 FOOT LLC

Table of content: (NPI 1720174675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720174675 NPI number — THE SHOE FITS AT 1 FOOT 2 FOOT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE SHOE FITS AT 1 FOOT 2 FOOT 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:
1720174675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 55350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23471-9350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-318-7002
Provider Business Mailing Address Fax Number:
757-318-7003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
173 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUFFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23434-4507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-934-0768
Provider Business Practice Location Address Fax Number:
757-925-1901
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAIRMAN
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
CRAIG
Authorized Official Title or Position:
PRESIDENT/MEDICAL DIRECTOR
Authorized Official Telephone Number:
757-934-0768

Provider Taxonomy Codes

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

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

  • Identifier: 5966790001 . This is a "MEDICARE DMERC" identifier . This identifiers is of the category "OTHER".




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