Provider Demographics
NPI:1558539338
Name:LISA E ROSTVOLD
Entity Type:Organization
Organization Name:LISA E ROSTVOLD
Other - Org Name:BLUE MOON SHOES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:ROSTVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED PEDORTHIST
Authorized Official - Phone:574-267-5537
Mailing Address - Street 1:110 N BUFFALO ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-2754
Mailing Address - Country:US
Mailing Address - Phone:574-267-5537
Mailing Address - Fax:574-267-6165
Practice Address - Street 1:110 N BUFFALO ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-2754
Practice Address - Country:US
Practice Address - Phone:574-267-5537
Practice Address - Fax:574-267-6165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INCPED2624335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier