Provider Demographics
NPI:1063637601
Name:ALBERTS ORTHOTICS AND SHOE MODIFICATIONS
Entity Type:Organization
Organization Name:ALBERTS ORTHOTICS AND SHOE MODIFICATIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-682-5722
Mailing Address - Street 1:112 W RAILROAD ST STE B
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65240-1380
Mailing Address - Country:US
Mailing Address - Phone:573-682-5722
Mailing Address - Fax:573-682-1546
Practice Address - Street 1:112 W RAILROAD ST STE B
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:MO
Practice Address - Zip Code:65240-1380
Practice Address - Country:US
Practice Address - Phone:573-682-5722
Practice Address - Fax:573-682-5722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO=========OtherTAX ID NUMBER
MO=========OtherTAX ID NUMBER