Provider Demographics
NPI:1902023849
Name:THE BOOTERY, INC.
Entity Type:Organization
Organization Name:THE BOOTERY, INC.
Other - Org Name:BOB JOHNS FAMILY SHOES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED PEDORTHIST
Authorized Official - Phone:419-227-2829
Mailing Address - Street 1:1400 ALLENTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2204
Mailing Address - Country:US
Mailing Address - Phone:419-227-2829
Mailing Address - Fax:419-227-7699
Practice Address - Street 1:1400 ALLENTOWN RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2204
Practice Address - Country:US
Practice Address - Phone:419-227-2829
Practice Address - Fax:419-227-7699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPED.20174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0539706Medicaid
OH0539706Medicaid