Healthcare Provider Details

I. General information

NPI: 1790900249
Provider Name (Legal Business Name): LESTERS DIABETIC SHOE SERV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 BLAIR CIRCLE
ESTILL SC
29918
US

IV. Provider business mailing address

PO BOX 632 41 BLAIR CIRCLE
ESTILL SC
29918
US

V. Phone/Fax

Practice location:
  • Phone: 803-625-4100
  • Fax: 803-625-4100
Mailing address:
  • Phone: 803-625-4100
  • Fax: 803-625-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code211D00000X
TaxonomyPodiatric Assistant
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateSC

VIII. Authorized Official

Name: MRS. ETHEL B DANDY
Title or Position: PEDORTHIC OWNER
Credential: PEDORTHIC CPED
Phone: 803-625-4100