Provider Demographics
NPI:1376624064
Name:DRS. FOOT SOURCE, INC.
Entity Type:Organization
Organization Name:DRS. FOOT SOURCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:S
Authorized Official - Last Name:SODERSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-262-8822
Mailing Address - Street 1:101 OAKRIDGE CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4100
Mailing Address - Country:US
Mailing Address - Phone:920-262-8822
Mailing Address - Fax:920-262-6337
Practice Address - Street 1:101 OAKRIDGE CT
Practice Address - Street 2:SUITE B
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4100
Practice Address - Country:US
Practice Address - Phone:920-262-8822
Practice Address - Fax:920-262-6337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41736500Medicaid
WI4006320001Medicare NSC