Provider Demographics
NPI:1396168290
Name:DIABETIC SHOE SOURCE
Entity type:Organization
Organization Name:DIABETIC SHOE SOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:PHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:601-506-5689
Mailing Address - Street 1:104 MCAULEY DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-2825
Mailing Address - Country:US
Mailing Address - Phone:601-883-3342
Mailing Address - Fax:601-856-5955
Practice Address - Street 1:104 MCAULEY DR
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2825
Practice Address - Country:US
Practice Address - Phone:601-883-3342
Practice Address - Fax:601-856-5955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies