Provider Demographics
NPI:1013167253
Name:LEBO'S SHOE STORE, INC
Entity Type:Organization
Organization Name:LEBO'S SHOE STORE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOOT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-641-4243
Mailing Address - Street 1:2321 CROWN CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-7705
Mailing Address - Country:US
Mailing Address - Phone:704-321-5000
Mailing Address - Fax:
Practice Address - Street 1:7300 E INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-9400
Practice Address - Country:US
Practice Address - Phone:704-535-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier