Provider Demographics
NPI:1720267073
Name:DALES BOOTERY LLC
Entity Type:Organization
Organization Name:DALES BOOTERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:HEROLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-473-4093
Mailing Address - Street 1:155 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-1903
Mailing Address - Country:US
Mailing Address - Phone:262-473-4093
Mailing Address - Fax:262-473-4946
Practice Address - Street 1:155 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1903
Practice Address - Country:US
Practice Address - Phone:262-473-4093
Practice Address - Fax:262-473-4946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CPED1589332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6173780001Medicare NSC