Healthcare Provider Details

I. General information

NPI: 1861407561
Provider Name (Legal Business Name): VAGABOND SHOES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 INTEGRITY WAY
APPLETON WI
54913-8464
US

IV. Provider business mailing address

1243 BEECHWOOD CT
GREEN BAY WI
54313-7261
US

V. Phone/Fax

Practice location:
  • Phone: 920-882-3989
  • Fax: 920-882-3988
Mailing address:
  • Phone: 920-606-0163
  • Fax: 920-882-3988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateWI

VIII. Authorized Official

Name: KATHLEEN M KELNHOFER
Title or Position: OWNER
Credential:
Phone: 920-606-0163