Healthcare Provider Details

I. General information

NPI: 1558316851
Provider Name (Legal Business Name): PACIFIC FOOTWEAR COMPANY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10240 SW NIMBUS AVE SUITE L1
PORTLAND OR
97223
US

IV. Provider business mailing address

10240 SW NIMBUS AVE STE L1
PORTLAND OR
97223-4360
US

V. Phone/Fax

Practice location:
  • Phone: 503-524-9656
  • Fax: 503-524-8397
Mailing address:
  • Phone: 503-524-9656
  • Fax: 503-524-8397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNULL

VIII. Authorized Official

Name: GENETTE ACUNA
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 503-524-9656