Provider Demographics
NPI:1700812245
Name:SHIPPY SHOE STORE, INC
Entity Type:Organization
Organization Name:SHIPPY SHOE STORE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SHIPPY
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED PEDORTHIST
Authorized Official - Phone:715-344-6993
Mailing Address - Street 1:5474 US HIGHWAY 10 E
Mailing Address - Street 2:SUITE 6
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-9115
Mailing Address - Country:US
Mailing Address - Phone:715-344-6993
Mailing Address - Fax:715-344-6658
Practice Address - Street 1:5474 US HIGHWAY 10 E
Practice Address - Street 2:SUITE 6
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-9115
Practice Address - Country:US
Practice Address - Phone:715-344-6993
Practice Address - Fax:715-344-6658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41722000Medicaid
WI4058360001Medicare ID - Type Unspecified