Provider Demographics
NPI:1811171127
Name:NORTHEAST SHOE
Entity type:Organization
Organization Name:NORTHEAST SHOE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TIERNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-465-2135
Mailing Address - Street 1:INTERSECTION RR 11 & RT 706
Mailing Address - Street 2:RR 3 BOX 22C
Mailing Address - City:NEW MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18834-9708
Mailing Address - Country:US
Mailing Address - Phone:570-465-2135
Mailing Address - Fax:570-465-5400
Practice Address - Street 1:INTERSECTION RR 11 & RT 706
Practice Address - Street 2:RR 3 BOX 22C
Practice Address - City:NEW MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18834-9708
Practice Address - Country:US
Practice Address - Phone:570-465-2135
Practice Address - Fax:570-465-5400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6056990001Medicare NSC