Provider Demographics
NPI:1275628323
Name:SOLE SUPPORT RESTORATIVE FOOTWEAR, LLC
Entity Type:Organization
Organization Name:SOLE SUPPORT RESTORATIVE FOOTWEAR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEINBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-421-9908
Mailing Address - Street 1:905 E. ALAMO STREET
Mailing Address - Street 2:
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77833
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 E. ALAMO STREET
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833
Practice Address - Country:US
Practice Address - Phone:979-421-9908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
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
TX531951OtherBLUE CROSS/BLUE SHIELD
TX531951OtherBLUE CROSS/BLUE SHIELD