Healthcare Provider Details

I. General information

NPI: 1518137405
Provider Name (Legal Business Name): DOC SHOES LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 05/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2717 MORRIS AVENUE
UNION NJ
07083
US

IV. Provider business mailing address

2717 MORRIS AVENUE
UNION NJ
07083
US

V. Phone/Fax

Practice location:
  • Phone: 908-349-8014
  • Fax: 908-349-8014
Mailing address:
  • Phone: 908-349-8014
  • Fax: 908-349-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number964
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number964
License Number StateMN

VIII. Authorized Official

Name: MR. BRIAN J. MULCAHY
Title or Position: CERTIFIED PEDORTHIST
Credential: C-PED
Phone: 908-349-8014