Provider Demographics
NPI:1447431945
Name:PROVOST SHOES
Entity Type:Organization
Organization Name:PROVOST SHOES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PROVOST
Authorized Official - Suffix:
Authorized Official - Credentials:C PED
Authorized Official - Phone:570-455-7704
Mailing Address - Street 1:25 LAUREL MALL
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18202-1201
Mailing Address - Country:US
Mailing Address - Phone:570-455-7704
Mailing Address - Fax:570-455-7704
Practice Address - Street 1:25 LAUREL MALL
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-1201
Practice Address - Country:US
Practice Address - Phone:570-455-7704
Practice Address - Fax:570-455-7704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA4244780002332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
A08009797OtherMEDICARE EDI BILLING NUMB
A08009797OtherMEDICARE EDI BILLING NUMB