Provider Demographics
NPI:1700076585
Name:YE OLDE COBBLER
Entity Type:Organization
Organization Name:YE OLDE COBBLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:FILONCZUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-682-0354
Mailing Address - Street 1:PO BOX 482
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-0482
Mailing Address - Country:US
Mailing Address - Phone:503-682-0354
Mailing Address - Fax:
Practice Address - Street 1:30605 SW MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-6757
Practice Address - Country:US
Practice Address - Phone:503-682-0354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR160655Medicaid
OR0412070001Medicare NSC