Provider Demographics
NPI:1356441950
Name:VAGABOND SHOES, INC.
Entity Type:Organization
Organization Name:VAGABOND SHOES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELNHOFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-606-0163
Mailing Address - Street 1:635 BAY PARK SQ
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5101
Mailing Address - Country:US
Mailing Address - Phone:920-606-0163
Mailing Address - Fax:920-498-2429
Practice Address - Street 1:635 BAY PARK SQ
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5101
Practice Address - Country:US
Practice Address - Phone:920-606-0163
Practice Address - Fax:920-498-2429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier