Healthcare Provider Details

I. General information

NPI: 1962542019
Provider Name (Legal Business Name): FOOTWEAR BY DESIGN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 03/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1967 LONGWOOD LAKE MARY RD SUITE 1001
LONGWOOD FL
32750-4673
US

IV. Provider business mailing address

1967 LONGWOOD LAKE MARY RD SUITE 1001
LONGWOOD FL
32750-4673
US

V. Phone/Fax

Practice location:
  • Phone: 407-323-7441
  • Fax: 407-323-1964
Mailing address:
  • Phone: 407-323-7441
  • Fax: 407-323-1964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPED154
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPED154
License Number StateFL

VIII. Authorized Official

Name: MRS. PAMELA ANN ECKENRODE
Title or Position: OWNER
Credential: L.C.PED
Phone: 407-323-7441