Provider Demographics
NPI:1245615517
Name:CHAMPION SHOE SALES & REPAIR INC
Entity Type:Organization
Organization Name:CHAMPION SHOE SALES & REPAIR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-523-0822
Mailing Address - Street 1:119 N 2ND ST REAR
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-1564
Mailing Address - Country:US
Mailing Address - Phone:570-523-0822
Mailing Address - Fax:570-523-0846
Practice Address - Street 1:119 N 2ND ST REAR
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-1564
Practice Address - Country:US
Practice Address - Phone:570-523-0822
Practice Address - Fax:570-523-0846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000005305332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7384940001Medicare NSC
PA7384940000Medicare NSC