Provider Demographics
NPI:1912447053
Name:STYLE SHOP
Entity Type:Organization
Organization Name:STYLE SHOP
Other - Org Name:MOUNTAIN INSOLES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BOLLIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-919-6917
Mailing Address - Street 1:555 TWINING FLATS RD
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-3119
Mailing Address - Country:US
Mailing Address - Phone:303-919-6917
Mailing Address - Fax:
Practice Address - Street 1:555 TWINING FLATS RD
Practice Address - Street 2:
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-3119
Practice Address - Country:US
Practice Address - Phone:303-919-6917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier