Provider Demographics
NPI:1689807299
Name:JEFFREY L BOUSE
Entity Type:Organization
Organization Name:JEFFREY L BOUSE
Other - Org Name:HAYES SHOE STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-885-7312
Mailing Address - Street 1:103 S SMITH ST
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-1235
Mailing Address - Country:US
Mailing Address - Phone:573-885-7312
Mailing Address - Fax:573-885-7312
Practice Address - Street 1:103 S SMITH ST
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:MO
Practice Address - Zip Code:65453-1235
Practice Address - Country:US
Practice Address - Phone:573-885-7312
Practice Address - Fax:573-885-7312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-29
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6706830001Medicare NSC