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General NPI Number Information
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NPI Number | 1346629029
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Entity Type | Organization
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Legal Business Name | LAKE CITY SHOE REPAIR
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Dates
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Enumeration Date | 05/27/2015
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Last Update Date | 11/12/2015
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Provider Practice Location Address
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Address Line | 3115 N GOVERNMENT WAY #7
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City | COEUR D ALENE
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State | ID
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Zip | 83815-3790
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Country | US
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Telephone | 208-762-0797
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Fax | 208-762-0791
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Provider Business Mailing Address
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Address Line | 3115 N GOVERNMENT WAY #7
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City | COEUR D ALENE
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State | ID
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Zip | 83815-3790
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Country | US
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Telephone | 208-762-0797
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Fax | 208-762-0791
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Authorized Official
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Title or Position | SENIOR PARTNOR
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Name | WAYNE C JOHNSON
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Credential | CPED
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Telephone | 208-762-0797
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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 | NOT REQUIRED
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License Number State | ID
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