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General NPI Number Information
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NPI Number | 1609135029
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Entity Type | Organization
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Legal Business Name | M&G CUSTOM SHOES AND ORTHOTICS LLC
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Dates
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Enumeration Date | 05/04/2012
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Last Update Date | 05/09/2012
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Provider Practice Location Address
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Address Line | 2950 BUSKIRK AVE SUITE 300
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City | WALNUT CREEK
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State | CA
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Zip | 94597-7779
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Country | US
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Telephone | 925-305-1855
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Fax | 925-755-8601
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Provider Business Mailing Address
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Address Line | 1504 A ST
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City | ANTIOCH
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State | CA
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Zip | 94509-2333
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Country | US
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Telephone | 925-305-1855
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Fax | 925-755-8601
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Authorized Official
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Title or Position | OWNER/PARTNER
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Name | MR. GREGORY R BANTING
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Credential | C.PED.
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Telephone | 925-305-1855
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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 | CPED0350
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License Number State | CA
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