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General NPI Number Information
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NPI Number | 1790846020
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Entity Type | Organization
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Legal Business Name | THE DOCTORS SHOE STORE
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Dates
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Enumeration Date | 12/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1228 SE PORT ST LUCIE BLVD
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City | PORT ST LUCIE
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State | FL
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Zip | 34952-5330
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Country | US
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Telephone | 772-380-9998
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Fax |
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Provider Business Mailing Address
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Address Line | 1228 SE PORT ST LUCIE BLVD
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City | PORT ST LUCIE
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State | FL
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Zip | 34952-5330
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Country | US
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Telephone | 772-380-9998
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. RUSSELL MILES BLATSTEIN
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Credential | DPM
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Telephone | 772-380-9998
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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 | 121954071029341
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License Number State | FL
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