Organization Name: | DIABETIC SHOE SOURCE |
NPI Number: | 1003960147 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | MARK AHLGREN (PRESIDENT) |
Mailing Address: | 7362 University Ave Ne Suite 306 Fridley |
State: | MN US |
Postal Code: | 554323142 |
Phone Number: | 7637578086 |
Fax Number: | 7638624797 |
NPI Enumeration Date: | 01/23/2007 |
NPI Last Update Date: | 03/10/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 332B00000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Suppliers |
Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
Taxonomy Specialization: | |
Taxonomy Definition: | A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient |