Provider Demographics
NPI:1821344706
Name:COUNTRY COBBLER, LTD.
Entity Type:Organization
Organization Name:COUNTRY COBBLER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MANTEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-772-9994
Mailing Address - Street 1:255 N EQUITY DR STE A
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-6054
Mailing Address - Country:US
Mailing Address - Phone:919-989-6190
Mailing Address - Fax:919-989-6127
Practice Address - Street 1:255 N EQUITY DR STE A
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-6054
Practice Address - Country:US
Practice Address - Phone:919-989-6190
Practice Address - Fax:919-989-6127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00992335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4649710002Medicare NSC