Provider Demographics
NPI:1467403055
Name:PROFESSIONAL FOOTWEAR LLC
Entity Type:Organization
Organization Name:PROFESSIONAL FOOTWEAR LLC
Other - Org Name:DBA THE FITTED FOOT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:NICHALSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-522-3800
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-0707
Mailing Address - Country:US
Mailing Address - Phone:812-522-3800
Mailing Address - Fax:812-522-3883
Practice Address - Street 1:1239 E 4TH STREET RD
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-1839
Practice Address - Country:US
Practice Address - Phone:812-522-3800
Practice Address - Fax:812-522-3883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200904040 AMedicaid
IN5833140001Medicare NSC