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General NPI Number Information
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NPI Number | 1144354283
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Entity Type | Organization
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Legal Business Name | FREMONT SHOE REPAIR TRU FIT PEDORTHICS
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 124 S STEWART AVE
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City | FREMONT
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State | MI
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Zip | 49412-1624
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Country | US
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Telephone | 231-924-0222
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Fax | 231-924-3855
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Provider Business Mailing Address
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Address Line | 124 S STEWART AVE
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City | FREMONT
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State | MI
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Zip | 49412-1624
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Country | US
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Telephone | 231-924-0222
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Fax | 231-924-3855
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. CHARLES THOMAS DEKRYGER
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Credential | C. PED.
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Telephone | 231-924-0222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State | MI
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