Provider Demographics
NPI:1376570408
Name:FOOT PAIN RELIEF STORE LLC
Entity Type:Organization
Organization Name:FOOT PAIN RELIEF STORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-374-0818
Mailing Address - Street 1:12406 TOEPPERWEIN RD
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3230
Mailing Address - Country:US
Mailing Address - Phone:210-326-8889
Mailing Address - Fax:
Practice Address - Street 1:12406 TOEPPERWEIN RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3230
Practice Address - Country:US
Practice Address - Phone:210-326-8889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NOT APPLICABLE335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX531408OtherBLUE CROSS BLUE SHIELD
TX=========001OtherTRICARE
TX531408OtherBLUE CROSS BLUE SHIELD
TX=========OtherPHCS
TX=========OtherHUMANA