Provider Demographics
NPI:1972743268
Name:PROVOST SHOES
Entity Type:Organization
Organization Name:PROVOST SHOES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:PROVOST
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:570-784-4645
Mailing Address - Street 1:225 COLUMBIA MALL DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-8368
Mailing Address - Country:US
Mailing Address - Phone:570-784-4645
Mailing Address - Fax:570-455-7704
Practice Address - Street 1:225 COLUMBIA MALL DR
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-8368
Practice Address - Country:US
Practice Address - Phone:570-784-4645
Practice Address - Fax:570-455-7704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA4244780001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4244780001Medicare NSC