Provider Demographics
NPI:1811102460
Name:STAR SHOES CORPORATION
Entity type:Organization
Organization Name:STAR SHOES CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-225-4569
Mailing Address - Street 1:3370 SUGARLOAF PKWY
Mailing Address - Street 2:SUITE G-6
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5478
Mailing Address - Country:US
Mailing Address - Phone:678-225-4569
Mailing Address - Fax:678-225-5749
Practice Address - Street 1:3370 SUGARLOAF PARKWAY
Practice Address - Street 2:SUITE G-6
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5478
Practice Address - Country:US
Practice Address - Phone:678-225-4569
Practice Address - Fax:678-225-5749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5945900001Medicare NSC