Provider Demographics
NPI:1598936536
Name:THE SHOE SMITH LLC
Entity Type:Organization
Organization Name:THE SHOE SMITH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:C PED
Authorized Official - Phone:860-423-8873
Mailing Address - Street 1:503 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-3143
Mailing Address - Country:US
Mailing Address - Phone:860-423-8873
Mailing Address - Fax:860-456-0373
Practice Address - Street 1:503 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-3143
Practice Address - Country:US
Practice Address - Phone:860-423-8873
Practice Address - Fax:860-456-0373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004201381Medicaid
CT004201381Medicaid