Healthcare Provider Details

I. General information

NPI: 1730436197
Provider Name (Legal Business Name): J. AVENDANO'S SHOES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2012
Last Update Date: 09/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 N FEDERAL HWY
POMPANO BEACH FL
33062-3705
US

IV. Provider business mailing address

1290 N FEDERAL HWY
POMPANO BEACH FL
33062-3705
US

V. Phone/Fax

Practice location:
  • Phone: 954-943-9667
  • Fax: 954-941-9204
Mailing address:
  • Phone: 954-943-9667
  • Fax: 954-941-9204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPED159
License Number StateFL

VIII. Authorized Official

Name: MS. EMERALD ZETA BARBAJO
Title or Position: PEDORTHIST
Credential: L.PED.
Phone: 954-573-3516