Provider Demographics
NPI:1518907492
Name:THE DIABETIC SHOE CORPORATION
Entity Type:Organization
Organization Name:THE DIABETIC SHOE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISQAY
Authorized Official - Middle Name:AYO
Authorized Official - Last Name:OTIKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:714-334-6214
Mailing Address - Street 1:2661 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4793
Mailing Address - Country:US
Mailing Address - Phone:323-583-4440
Mailing Address - Fax:
Practice Address - Street 1:2661 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4793
Practice Address - Country:US
Practice Address - Phone:323-583-4440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4159332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies