Healthcare Provider Details

I. General information

NPI: 1447431945
Provider Name (Legal Business Name): PROVOST SHOES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 LAUREL MALL
HAZLETON PA
18202-1201
US

IV. Provider business mailing address

25 LAUREL MALL
HAZLETON PA
18202-1201
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-7704
  • Fax: 570-455-7704
Mailing address:
  • Phone: 570-455-7704
  • Fax: 570-455-7704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4244780002
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierA08009797
Identifier TypeOTHER
Identifier State
Identifier IssuerMEDICARE EDI BILLING NUMB

VIII. Authorized Official

Name: JOHN M PROVOST
Title or Position: OWNER
Credential: C. PED
Phone: 570-455-7704