Provider Demographics
NPI:1073724274
Name:THREE LEGGED DOG, LLC
Entity Type:Organization
Organization Name:THREE LEGGED DOG, LLC
Other - Org Name:FOOT SOLUTIONS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-573-9277
Mailing Address - Street 1:2315 FOREST DR STE C
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3837
Mailing Address - Country:US
Mailing Address - Phone:410-573-9277
Mailing Address - Fax:410-573-9278
Practice Address - Street 1:2315 FOREST DR STE C
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3837
Practice Address - Country:US
Practice Address - Phone:410-573-9277
Practice Address - Fax:410-573-9278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5727720001Medicare ID - Type Unspecified