=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649449315
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HILTON HEAD SHOE REPAIR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2008
-----------------------------------------------------
Last Update Date | 02/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 OTTER HOLE RD SUITE 10
-----------------------------------------------------
City | HILTON HEAD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29926-2284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-342-9425
-----------------------------------------------------
Fax | 843-342-9425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 OTTER HOLE RD SUITE 10
-----------------------------------------------------
City | HILTON HEAD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29926-2284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-342-9425
-----------------------------------------------------
Fax | 843-342-9425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GARY EUGENE FLOWERS
-----------------------------------------------------
Credential | PEDORTHISTS
-----------------------------------------------------
Telephone | 843-342-9425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------