Provider Demographics
NPI:1790900249
Name:LESTERS DIABETIC SHOE SERV
Entity Type:Organization
Organization Name:LESTERS DIABETIC SHOE SERV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDORTHIC OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:DANDY
Authorized Official - Suffix:
Authorized Official - Credentials:PEDORTHIC CPED
Authorized Official - Phone:803-625-4100
Mailing Address - Street 1:PO BOX 632
Mailing Address - Street 2:41 BLAIR CIRCLE
Mailing Address - City:ESTILL
Mailing Address - State:SC
Mailing Address - Zip Code:29918
Mailing Address - Country:US
Mailing Address - Phone:803-625-4100
Mailing Address - Fax:803-625-4100
Practice Address - Street 1:41 BLAIR CIRCLE
Practice Address - Street 2:
Practice Address - City:ESTILL
Practice Address - State:SC
Practice Address - Zip Code:29918
Practice Address - Country:US
Practice Address - Phone:803-625-4100
Practice Address - Fax:803-625-4100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC211D00000X, 332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, PodiatricGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5177800001Medicare ID - Type Unspecified