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General NPI Number Information
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NPI Number | 1063778884
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Entity Type | Organization
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Legal Business Name | SOLE SOURCE LLC YOUR DIABETIC SHOE STORE
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Dates
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Enumeration Date | 04/05/2012
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Last Update Date | 05/22/2012
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Provider Practice Location Address
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Address Line | 50 N HURON ST
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City | YPSILANTI
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State | MI
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Zip | 48197-2608
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Country | US
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Telephone | 734-340-9614
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Fax | 734-879-2774
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Provider Business Mailing Address
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Address Line | 50 N HURON ST
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City | YPSILANTI
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State | MI
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Zip | 48197-2608
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Country | US
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Telephone | 734-340-9614
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Fax | 734-879-2774
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Authorized Official
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Title or Position | SHOE FITTER
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Name | ANNETTE BOTTUM
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Credential |
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Telephone | 734-340-9614
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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