Provider Demographics
NPI:1689811986
Name:RIVER BEND SHOE CENTER
Entity Type:Organization
Organization Name:RIVER BEND SHOE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GAWLITTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-543-0400
Mailing Address - Street 1:7508 W OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53219-2860
Mailing Address - Country:US
Mailing Address - Phone:414-543-0400
Mailing Address - Fax:
Practice Address - Street 1:7508 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53219-2860
Practice Address - Country:US
Practice Address - Phone:414-543-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI004000037355701335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier