Provider Demographics
NPI:1619089992
Name:DIMITRI'S SHOE SERVICE,LLC
Entity Type:Organization
Organization Name:DIMITRI'S SHOE SERVICE,LLC
Other - Org Name:RED WING SHOES AND REPAIR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED PEDORTHIST
Authorized Official - Phone:419-893-8647
Mailing Address - Street 1:209 CONANT ST
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-3355
Mailing Address - Country:US
Mailing Address - Phone:419-893-8647
Mailing Address - Fax:419-893-8694
Practice Address - Street 1:209 CONANT ST
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-3355
Practice Address - Country:US
Practice Address - Phone:419-893-8647
Practice Address - Fax:419-893-8694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies