Provider Demographics
NPI:1477720894
Name:PARK SHOES INC.
Entity Type:Organization
Organization Name:PARK SHOES INC.
Other - Org Name:VILLAGE BOOTERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SALES/BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-283-3833
Mailing Address - Street 1:2641 SE OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34996-3401
Mailing Address - Country:US
Mailing Address - Phone:772-746-3536
Mailing Address - Fax:772-744-7851
Practice Address - Street 1:2641 SE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-3401
Practice Address - Country:US
Practice Address - Phone:772-746-3536
Practice Address - Fax:772-744-7851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5114170001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5114170001Medicare NSC