Healthcare Provider Details

I. General information

NPI: 1841581717
Provider Name (Legal Business Name): PACIFIC FOOTWEAR COMPANY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 TOWN CENTRE DR STE A
MEDFORD OR
97504-6188
US

IV. Provider business mailing address

10240 SW NIMBUS AVE SUITE L1
PORTLAND OR
97223-4358
US

V. Phone/Fax

Practice location:
  • Phone: 547-608-7400
  • Fax: 541-608-7600
Mailing address:
  • Phone: 503-524-9565
  • Fax: 503-524-8397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: KEVIN W CLARKE
Title or Position: PRESIDENT
Credential:
Phone: 503-524-9656