=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003960147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIABETIC SHOE SOURCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 10/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 CLIFF DR STE 118
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55122-3431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-757-8086
-----------------------------------------------------
Fax | 763-862-4797
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 CLIFF DR STE 118
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55122-3431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-757-8086
-----------------------------------------------------
Fax | 763-862-4797
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | AMY LUZAICH
-----------------------------------------------------
Credential | CFTS
-----------------------------------------------------
Telephone | 763-757-8086
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
=====================================================
Legacy Identifiers
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 786A6DI
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | MN
-----------------------------------------------------
Identifier Issuer | BCBS
-----------------------------------------------------
Identifier #2
-----------------------------------------------------
Identifier Code | 520052200
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | MN
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
=====================================================
Proprietary Identifiers Ever Reported
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 520052200
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | MN
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
Identifier #2
-----------------------------------------------------
Identifier Code | 786A6DI
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | MN
-----------------------------------------------------
Identifier Issuer | BCBS
-----------------------------------------------------