Provider Demographics
NPI:1861632671
Name:PACIFIC FOOTWEAR COMPANY, INC
Entity Type:Organization
Organization Name:PACIFIC FOOTWEAR COMPANY, INC
Other - Org Name:PRIORITY FOOTWEAR & PEDORTHIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:REIMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-524-9656
Mailing Address - Street 1:10240 SW NIMBUS AVE
Mailing Address - Street 2:SUITE L1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-4358
Mailing Address - Country:US
Mailing Address - Phone:503-524-9656
Mailing Address - Fax:503-524-8397
Practice Address - Street 1:45 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-688-5787
Practice Address - Fax:801-295-2445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT260051087001Medicaid
OR5518680001Medicare NSC