Healthcare Provider Details

I. General information

NPI: 1437301074
Provider Name (Legal Business Name): ANTONIO MARIO SERGIO SR. REG SHOE-MAKER MERCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 MISHAWAKA AVENUE
SOUTH BEND IN
46615-1426
US

IV. Provider business mailing address

1508 MISHAWAKA AVENUE
SOUTH BEND IN
46615-1426
US

V. Phone/Fax

Practice location:
  • Phone: 574-246-9700
  • Fax:
Mailing address:
  • Phone: 574-246-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: