Provider Demographics
NPI:1891831319
Name:PHELPS, INC
Entity Type:Organization
Organization Name:PHELPS, INC
Other - Org Name:PHELPS SHOES & REPAIR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:303-776-9762
Mailing Address - Street 1:2255 N MAIN ST
Mailing Address - Street 2:STE 103
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1488
Mailing Address - Country:US
Mailing Address - Phone:303-776-9762
Mailing Address - Fax:303-776-4152
Practice Address - Street 1:2255 N MAIN ST
Practice Address - Street 2:STE 103
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1488
Practice Address - Country:US
Practice Address - Phone:303-776-9762
Practice Address - Fax:303-776-4152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4120020001Medicare ID - Type Unspecified