Healthcare Provider Details

I. General information

NPI: 1871893321
Provider Name (Legal Business Name): SHOEMATE ORTHOTICS CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 11/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 COLLINS RD NE PMB 230
CEDAR RAPIDS IA
52402-3229
US

IV. Provider business mailing address

162 COLLINS RD NE PMB 230
CEDAR RAPIDS IA
52402-3229
US

V. Phone/Fax

Practice location:
  • Phone: 905-873-4884
  • Fax:
Mailing address:
  • Phone: 905-873-4884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. PETER GLOGOWSKI
Title or Position: VICE PRESIDENT
Credential:
Phone: 905-873-4884