Provider Demographics
NPI:1134476468
Name:BOB JOHNS SHOES, PEDORTHICS & REPAIR
Entity Type:Organization
Organization Name:BOB JOHNS SHOES, PEDORTHICS & REPAIR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:419-227-2829
Mailing Address - Street 1:2110 SPENCERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3442
Mailing Address - Country:US
Mailing Address - Phone:419-227-2829
Mailing Address - Fax:
Practice Address - Street 1:2110 SPENCERVILLE RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-3442
Practice Address - Country:US
Practice Address - Phone:419-227-2829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-06
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPED.20332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6687490001Medicare NSC