Provider Demographics
NPI:1013096437
Name:B C SHOES INC.
Entity Type:Organization
Organization Name:B C SHOES INC.
Other - Org Name:BURKHARTZMEYER SHOES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BURKHARTZMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:OST, C PED
Authorized Official - Phone:507-334-7774
Mailing Address - Street 1:128 CENTRAL AVE N
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5298
Mailing Address - Country:US
Mailing Address - Phone:507-334-7774
Mailing Address - Fax:507-334-9256
Practice Address - Street 1:128 CENTRAL AVE N
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5298
Practice Address - Country:US
Practice Address - Phone:507-334-7774
Practice Address - Fax:507-334-9256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-05
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0920230001Medicare ID - Type Unspecified