Provider Demographics
NPI:1700862281
Name:THE DIABETIC SHOE CORP
Entity Type:Organization
Organization Name:THE DIABETIC SHOE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:OTIKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-766-6776
Mailing Address - Street 1:10639 BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:N HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-2512
Mailing Address - Country:US
Mailing Address - Phone:866-712-7463
Mailing Address - Fax:818-508-1819
Practice Address - Street 1:10639 BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:N HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-2512
Practice Address - Country:US
Practice Address - Phone:866-712-7463
Practice Address - Fax:818-508-1819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4159332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4875930001OtherDMERC