MEDICARE: OLD SOULS NEW SHOES 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	:	1740551043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLD SOULS NEW SHOES LLC

Provider Business Mailing Address
First Line	:	513 CHESTER AVE
Second Line	:
City	:	GREAT FALLS
State	:	SC
Zip	:	29055-1219
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	513 CHESTER AVE
Second Line	:
City	:	GREAT FALLS
State	:	SC
Zip	:	29055-1219
Country	:	US
Telephone Number	:	704-970-8237
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. CHAD MULLINS
Credential	:
Telephone Number	:	704-970-8237

Provider Enumeration Date	:	01/18/2012
Last Update Date	:	01/18/2012

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