Provider Demographics
NPI:1013900729
Name:JAFFE SHOE STORES, INC.
Entity type:Organization
Organization Name:JAFFE SHOE STORES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CERTIIED PEDORTHIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SONNY
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:423-892-3366
Mailing Address - Street 1:PO BOX 80024
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37414-7024
Mailing Address - Country:US
Mailing Address - Phone:423-892-3366
Mailing Address - Fax:423-892-3337
Practice Address - Street 1:5726 MARLIN RD
Practice Address - Street 2:SUITE 512
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-4008
Practice Address - Country:US
Practice Address - Phone:423-892-3366
Practice Address - Fax:423-892-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NO STATE LICENSURE335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454284Medicaid
TN4043199OtherBLUE CROSS
TN0368860001Medicare ID - Type Unspecified