Provider Demographics
NPI:1801026091
Name:LUCKY SHOES INC
Entity Type:Organization
Organization Name:LUCKY SHOES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-836-9542
Mailing Address - Street 1:600 SOUTHPARK CTR
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-9321
Mailing Address - Country:US
Mailing Address - Phone:440-572-5111
Mailing Address - Fax:
Practice Address - Street 1:600 SOUTHPARK CTR
Practice Address - Street 2:
Practice Address - City:STRONGSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44136-9321
Practice Address - Country:US
Practice Address - Phone:440-572-5111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
4266210003Medicare PIN