Provider Demographics
NPI:1649449315
Name:HILTON HEAD SHOE REPAIR
Entity type:Organization
Organization Name:HILTON HEAD SHOE REPAIR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:FLOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:PEDORTHISTS
Authorized Official - Phone:843-342-9425
Mailing Address - Street 1:29 OTTER HOLE RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:HILTON HEAD
Mailing Address - State:SC
Mailing Address - Zip Code:29926-2284
Mailing Address - Country:US
Mailing Address - Phone:843-342-9425
Mailing Address - Fax:843-342-9425
Practice Address - Street 1:29 OTTER HOLE RD
Practice Address - Street 2:SUITE 10
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29926-2284
Practice Address - Country:US
Practice Address - Phone:843-342-9425
Practice Address - Fax:843-342-9425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier