Healthcare Provider Details

I. General information

NPI: 1053555490
Provider Name (Legal Business Name): SHOBY SHOES LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 04/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11514 GOODLOE RD
SILVER SPRING MD
20906-4838
US

IV. Provider business mailing address

11514 GOODLOE RD
SILVER SPRING MD
20906-4838
US

V. Phone/Fax

Practice location:
  • Phone: 301-706-7796
  • Fax: 301-942-7288
Mailing address:
  • Phone: 301-706-7796
  • Fax: 301-942-7288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. INGRID VENTURA
Title or Position: EXECUTIVE DIRECTOR
Credential: B.S.
Phone: 391-942-7288