=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144205766
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHOES ETC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2005
-----------------------------------------------------
Last Update Date | 07/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7229 SAINT ANDREWS RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29212-1178
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-781-5757
-----------------------------------------------------
Fax | 888-341-1583
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2652
-----------------------------------------------------
City | IRMO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29063-4003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-781-5757
-----------------------------------------------------
Fax | 866-843-2602
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. TAMMY M HOLDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-781-5757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 032383439
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------