Provider Demographics
NPI:1346629029
Name:LAKE CITY SHOE REPAIR
Entity Type:Organization
Organization Name:LAKE CITY SHOE REPAIR
Other - Org Name:PARTNERSHIP
Other - Org Type:Other Name
Authorized Official - Title/Position:SENIOR PARTNOR
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:208-762-0797
Mailing Address - Street 1:3115 N GOVERNMENT WAY
Mailing Address - Street 2:#7
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-3790
Mailing Address - Country:US
Mailing Address - Phone:208-762-0797
Mailing Address - Fax:208-762-0791
Practice Address - Street 1:3115 N GOVERNMENT WAY
Practice Address - Street 2:#7
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-3790
Practice Address - Country:US
Practice Address - Phone:208-762-0797
Practice Address - Fax:208-762-0791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNOT REQUIRED332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID5127610001OtherPTAN