Provider Demographics
NPI:1750573648
Name:PAULS SHOE REPAIR AND SALES INC.
Entity type:Organization
Organization Name:PAULS SHOE REPAIR AND SALES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIROS
Authorized Official - Middle Name:
Authorized Official - Last Name:MISHIDZHYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-507-0314
Mailing Address - Street 1:1102 S GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-3203
Mailing Address - Country:US
Mailing Address - Phone:818-507-0314
Mailing Address - Fax:818-507-9962
Practice Address - Street 1:1102 S GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-3203
Practice Address - Country:US
Practice Address - Phone:818-507-0314
Practice Address - Fax:818-507-9962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4979280001Medicare NSC