MEDICARE: FOOTWEAR BY DESIGN

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	PED154	FL
2	332B00000X	Durable Medical Equipment & Medical Supplies	PED154	FL

General Provider Information

NPI Number	:	1962542019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTWEAR BY DESIGN

Provider Business Mailing Address
First Line	:	1967 LONGWOOD LAKE MARY RD
Second Line	:	SUITE 1001
City	:	LONGWOOD
State	:	FL
Zip	:	32750-4673
Country	:	US
Telephone Number	:	407-323-7441
Fax Number	:	407-323-1964

Provider Business Practice Location Address
First Line	:	1967 LONGWOOD LAKE MARY RD
Second Line	:	SUITE 1001
City	:	LONGWOOD
State	:	FL
Zip	:	32750-4673
Country	:	US
Telephone Number	:	407-323-7441
Fax Number	:	407-323-1964

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. PAMELA ANN ECKENRODE
Credential	:	L.C.PED
Telephone Number	:	407-323-7441

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	03/06/2009

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Directions to “FOOTWEAR BY DESIGN ” Practice Location

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