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General NPI Number Information
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NPI Number | 1972743268
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Entity Type | Organization
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Legal Business Name | PROVOST SHOES
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Dates
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Enumeration Date | 02/25/2009
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Last Update Date | 02/25/2009
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Provider Practice Location Address
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Address Line | 225 COLUMBIA MALL DR
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City | BLOOMSBURG
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State | PA
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Zip | 17815-8368
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Country | US
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Telephone | 570-784-4645
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Fax | 570-455-7704
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Provider Business Mailing Address
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Address Line | 225 COLUMBIA MALL DR
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City | BLOOMSBURG
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State | PA
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Zip | 17815-8368
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Country | US
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Telephone | 570-784-4645
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Fax | 570-455-7704
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Authorized Official
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Title or Position | OWNER
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Name | MR. JOHN MARSHALL PROVOST
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Credential | C.PED
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Telephone | 570-784-4645
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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 | 4244780001
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License Number State | PA
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