Provider Demographics
NPI:1497812002
Name:KALAMAZOO SHOE COMPANY, INC.
Entity Type:Organization
Organization Name:KALAMAZOO SHOE COMPANY, INC.
Other - Org Name:COREY'S BOOTERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:C PED
Authorized Official - Phone:269-349-2247
Mailing Address - Street 1:1016 E CORK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-4823
Mailing Address - Country:US
Mailing Address - Phone:269-349-2247
Mailing Address - Fax:269-349-0529
Practice Address - Street 1:1016 E CORK ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-4823
Practice Address - Country:US
Practice Address - Phone:269-349-2247
Practice Address - Fax:269-349-0529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5325920001Medicare ID - Type Unspecified