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General NPI Number Information
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NPI Number | 1780646653
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Entity Type | Organization
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Legal Business Name | COUNTRY COBBLER, LTD.
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Dates
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Enumeration Date | 04/05/2006
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Last Update Date | 09/18/2015
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Provider Practice Location Address
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Address Line | 3501 OLEANDER DR SUITE 11
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City | WILMINGTON
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State | NC
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Zip | 28403-0824
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Country | US
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Telephone | 910-772-9994
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Fax | 910-772-1262
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Provider Business Mailing Address
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Address Line | 3501 OLEANDER DR SUITE 11
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City | WILMINGTON
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State | NC
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Zip | 28403-0824
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Country | US
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Telephone | 910-772-9994
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Fax | 910-772-1262
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Authorized Official
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Title or Position | DIABETIC SHOE PROGRAM FACILITATOR
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Name | MR. MARK ALLEN MANTEY
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Credential |
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Telephone | 910-772-9994
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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 | 00992
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License Number State | NC
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