Healthcare Provider Details

I. General information

NPI: 1992598023
Provider Name (Legal Business Name): DIABETIC SHOE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 GREENBO BLVD
FLATWOODS KY
41139-1830
US

IV. Provider business mailing address

652 SPRING MEADOW DR
RADCLIFF KY
40160-9443
US

V. Phone/Fax

Practice location:
  • Phone: 606-644-3815
  • Fax:
Mailing address:
  • Phone: 606-644-3815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: SHANNON KISER
Title or Position: OWNER
Credential:
Phone: 606-644-3815