Provider Demographics
NPI:1093130833
Name:TIENDA DE ZAPATOS PIE DIVINO
Entity Type:Organization
Organization Name:TIENDA DE ZAPATOS PIE DIVINO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:787-801-0765
Mailing Address - Street 1:MUNOZ RIVERA 59
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738
Mailing Address - Country:US
Mailing Address - Phone:787-801-0765
Mailing Address - Fax:
Practice Address - Street 1:MUNOZ RIVERA 59
Practice Address - Street 2:
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-801-0765
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies