| Organization Name: | E. WAGNER'S SHOES |
| NPI Number: | 1104983337 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JERRY L. STOUT (OWNER) |
| Mailing Address: | 7379 North Ave River Forest |
| State: | IL US |
| Postal Code: | 603051230 |
| Phone Number: | 7087714528 |
| Fax Number: | |
| NPI Enumeration Date: | 01/03/2007 |
| NPI Last Update Date: | 12/17/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 335E00000X |
| License Number: | 0887330001 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Prosthetic/Orthotic Supplier |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An organization that provides prosthetic and orthotic care which may include, but is not limited to, patient evaluation, prosthesis or orthosis design, fabrication, fitting and modification to treat limb loss for purposes of restoring physiological function and/or cosmesis or to treat a neuromusculoskeletal disorder or acquired condition. |