Provider Demographics
NPI:1396917159
Name:STEVE'S SHOE SERVICE & PEDORTHIC CENTER
Entity type:Organization
Organization Name:STEVE'S SHOE SERVICE & PEDORTHIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:PETRARCA
Authorized Official - Suffix:
Authorized Official - Credentials:OST C PED
Authorized Official - Phone:401-885-5004
Mailing Address - Street 1:135 FRENCHTOWN ROAD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-1783
Mailing Address - Country:US
Mailing Address - Phone:401-885-5004
Mailing Address - Fax:401-885-8283
Practice Address - Street 1:135 FRENCHTOWN ROAD
Practice Address - Street 2:SUITE 4
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-1783
Practice Address - Country:US
Practice Address - Phone:401-885-5004
Practice Address - Fax:401-885-8283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
29672OtherBLUE CROSS
408288OtherBLUE CHIP
1247920001Medicare NSC