Provider Demographics
NPI:1669814406
Name:SHOE STORE, LLC
Entity Type:Organization
Organization Name:SHOE STORE, LLC
Other - Org Name:OPPEDISANO'S BOOTERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEDENBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-538-3376
Mailing Address - Street 1:12 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HONEOYE FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14472-1071
Mailing Address - Country:US
Mailing Address - Phone:180-091-3746
Mailing Address - Fax:
Practice Address - Street 1:12 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HONEOYE FALLS
Practice Address - State:NY
Practice Address - Zip Code:14472-1071
Practice Address - Country:US
Practice Address - Phone:180-091-3746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier