Healthcare Provider Details

I. General information

NPI: 1336136902
Provider Name (Legal Business Name): SHARI'S SHOES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 N MAIN ST
WATERBURY CT
06704-2713
US

IV. Provider business mailing address

1420 N MAIN ST
WATERBURY CT
06704-2713
US

V. Phone/Fax

Practice location:
  • Phone: 203-753-7463
  • Fax: 203-753-7463
Mailing address:
  • Phone: 203-753-7463
  • Fax: 203-753-7463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number9948
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number9948
License Number State

VIII. Authorized Official

Name: MISS SHARON FRANCES NUERAKIS
Title or Position: BOARD CERTIFIED PEDORTHIST
Credential: CPED
Phone: 203-753-7463