Provider Demographics
NPI:1801822937
Name:THE SHOE TREE, INC
Entity Type:Organization
Organization Name:THE SHOE TREE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:BOYLD
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-773-5571
Mailing Address - Street 1:801 DOLLIVER ST
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2503
Mailing Address - Country:US
Mailing Address - Phone:805-773-5571
Mailing Address - Fax:805-773-1270
Practice Address - Street 1:801 DOLLIVER ST
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-2503
Practice Address - Country:US
Practice Address - Phone:805-773-5571
Practice Address - Fax:805-773-1270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4752640001Medicare ID - Type Unspecified