Provider Demographics
NPI:1063680064
Name:NISSI CORP
Entity Type:Organization
Organization Name:NISSI CORP
Other - Org Name:THE GOOD FEET STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BUCKMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:CERTIFIED PEDORTHIST
Authorized Official - Phone:815-654-1900
Mailing Address - Street 1:5823 E RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-4963
Mailing Address - Country:US
Mailing Address - Phone:815-654-1900
Mailing Address - Fax:
Practice Address - Street 1:5823 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-4963
Practice Address - Country:US
Practice Address - Phone:815-654-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL212000137332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5906740001Medicare NSC