Provider Demographics
NPI:1831334978
Name:VILLAGE SHOE SERVICE, LLC
Entity type:Organization
Organization Name:VILLAGE SHOE SERVICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SCHUPBACH
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPED
Authorized Official - Phone:770-938-7463
Mailing Address - Street 1:4286 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4487
Mailing Address - Country:US
Mailing Address - Phone:770-938-7463
Mailing Address - Fax:
Practice Address - Street 1:4286 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4487
Practice Address - Country:US
Practice Address - Phone:770-938-7463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACPED2232335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier