Provider Demographics
NPI:1144205766
Name:SHOES ETC LLC
Entity Type:Organization
Organization Name:SHOES ETC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-781-5757
Mailing Address - Street 1:PO BOX 2652
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-4003
Mailing Address - Country:US
Mailing Address - Phone:803-781-5757
Mailing Address - Fax:866-843-2602
Practice Address - Street 1:7715 ST ANDREWS RD STE D
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2835
Practice Address - Country:US
Practice Address - Phone:803-781-5757
Practice Address - Fax:866-843-2602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC032383439332B00000X
10400 BCP335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2667Medicaid
SC5546490001Medicare NSC