=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871908194
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEARFOOT SHOES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2014
-----------------------------------------------------
Last Update Date | 04/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1205 MEDICAL PLAZA CT
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-900-2250
-----------------------------------------------------
Fax | 877-757-5233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1205 MEDICAL PLAZA CT
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048-5684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-900-2250
-----------------------------------------------------
Fax | 877-757-5233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. JOHN E SHERO
-----------------------------------------------------
Credential | C.PED
-----------------------------------------------------
Telephone | 817-894-9436
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------