Healthcare Provider Details

I. General information

NPI: 1073464350
Provider Name (Legal Business Name): GINOS WIDE SHOES & SHOE REPAIR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2026
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 GROSSMONT CENTER DR STE 141 STE 141
LA MESA CA
91942-3070
US

IV. Provider business mailing address

5500 GROSSMONT CENTER DR STE 141 STE 141
LA MESA CA
91942-3070
US

V. Phone/Fax

Practice location:
  • Phone: 619-433-4466
  • Fax: 619-439-6787
Mailing address:
  • Phone: 619-433-4466
  • Fax: 619-439-6787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: PABLO SERRANO JR.
Title or Position: OWNER
Credential:
Phone: 619-433-4466