MEDICARE: LUCKY SHOES INC

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1811127004
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUCKY SHOES INC

Provider Business Mailing Address
First Line	:	4840 EVERHARD RD NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44718-2413
Country	:	US
Telephone Number	:	330-494-7575
Fax Number	:

Provider Business Practice Location Address
First Line	:	4840 EVERHARD RD NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44718-2413
Country	:	US
Telephone Number	:	330-494-7575
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	JOHN LUCK
Credential	:
Telephone Number	:	330-836-9542

Provider Enumeration Date	:	07/22/2009
Last Update Date	:	07/22/2009

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Directions to “LUCKY SHOES INC ” Practice Location

Language	Start Address	Practice Location

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