MEDICARE: CLARKSON DIABETIC SHOES & MORE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1174753990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARKSON DIABETIC SHOES & MORE, LLC

Provider Business Mailing Address
First Line	:	722 W MAIN ST
Second Line	:
City	:	CLARKSON
State	:	KY
Zip	:	42726-7048
Country	:	US
Telephone Number	:	270-200-2100
Fax Number	:	270-200-2101

Provider Business Practice Location Address
First Line	:	722 W MAIN ST
Second Line	:
City	:	CLARKSON
State	:	KY
Zip	:	42726-7048
Country	:	US
Telephone Number	:	270-200-2100
Fax Number	:	270-200-2101

Authorized Official
Title or Position	:	OWNER
Name	:	MISS KATHY POWELL
Credential	:
Telephone Number	:	270-200-2100

Provider Enumeration Date	:	07/15/2009
Last Update Date	:	07/15/2009

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