Provider Demographics
NPI:1003960147
Name:DIABETIC SHOE SOURCE
Entity Type:Organization
Organization Name:DIABETIC SHOE SOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUZAICH
Authorized Official - Suffix:
Authorized Official - Credentials:CFTS
Authorized Official - Phone:763-757-8086
Mailing Address - Street 1:2121 CLIFF DR STE 118
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3431
Mailing Address - Country:US
Mailing Address - Phone:763-757-8086
Mailing Address - Fax:763-862-4797
Practice Address - Street 1:2121 CLIFF DR STE 118
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3431
Practice Address - Country:US
Practice Address - Phone:763-757-8086
Practice Address - Fax:763-862-4797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN786A6DIOtherBCBS
MN520052200Medicaid
5826800001Medicare NSC