MEDICARE: THE DIABETIC SHOE CORPORATION

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	E4159	CA

General Provider Information

NPI Number	:	1518907492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE DIABETIC SHOE CORPORATION

Provider Business Mailing Address
First Line	:	2661 E FLORENCE AVE
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4793
Country	:	US
Telephone Number	:	323-583-4440
Fax Number	:

Provider Business Practice Location Address
First Line	:	2661 E FLORENCE AVE
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4793
Country	:	US
Telephone Number	:	323-583-4440
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. CHRISQAY AYO OTIKO
Credential	:	DPM
Telephone Number	:	714-334-6214

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	08/22/2020

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