Provider Demographics
NPI:1710315486
Name:DYNASTY GLOBAL FOOTWEAR LLC
Entity Type:Organization
Organization Name:DYNASTY GLOBAL FOOTWEAR LLC
Other - Org Name:FOOT SOLUTIONS RICE VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:CLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-521-3668
Mailing Address - Street 1:1620 CENTRAL AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4557
Mailing Address - Country:US
Mailing Address - Phone:713-521-3668
Mailing Address - Fax:713-521-3668
Practice Address - Street 1:5318 KIRBY DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-1349
Practice Address - Country:US
Practice Address - Phone:713-521-3668
Practice Address - Fax:713-521-3668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2483332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies