Provider Demographics
NPI:1376576355
Name:KINGSMOUNT INC.
Entity Type:Organization
Organization Name:KINGSMOUNT INC.
Other - Org Name:FOOT COMFORT CENTER - ITALIAN SHOE WAREHOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SOFYA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMARKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-676-7463
Mailing Address - Street 1:9808 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-2190
Mailing Address - Country:US
Mailing Address - Phone:215-676-7463
Mailing Address - Fax:
Practice Address - Street 1:9808 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-2190
Practice Address - Country:US
Practice Address - Phone:215-676-7463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000005644332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1148890OtherPROV ID- KEYSTONE MERCY
PA240588OtherPROV ID - BLUE CROSS
PAHEALTH PARTNERSOther31636
PA0005147000OtherPROV ID - KEYSTONE HPE
PA0018439280002Medicaid
PAAMERICHOICEOther01843928-01
PA3987700001Medicare ID - Type UnspecifiedPROV ID