Provider Demographics
NPI:1265611891
Name:COUNTRYSIDE PEDORTHICS & COBBLER SHOP
Entity type:Organization
Organization Name:COUNTRYSIDE PEDORTHICS & COBBLER SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CERTIFIED PEDORTHIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:AUGER
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:860-546-1099
Mailing Address - Street 1:95 BINGHAM ROAD
Mailing Address - Street 2:
Mailing Address - City:CANTERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06331
Mailing Address - Country:US
Mailing Address - Phone:860-546-1099
Mailing Address - Fax:860-546-1095
Practice Address - Street 1:95 BINGHAM RD
Practice Address - Street 2:
Practice Address - City:CANTERBURY
Practice Address - State:CT
Practice Address - Zip Code:06331-1302
Practice Address - Country:US
Practice Address - Phone:860-546-1099
Practice Address - Fax:860-546-1095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1510332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004069993Medicaid
CT004069993Medicaid