| Organization Name: | LAKE CITY SHOE REPAIR |
| NPI Number: | 1346629029 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | WAYNE C JOHNSON (SENIOR PARTNOR) |
| Mailing Address: | 3115 N Government Way #7 Coeur D Alene |
| State: | ID US |
| Postal Code: | 838153790 |
| Phone Number: | 2087620797 |
| Fax Number: | 2087620791 |
| NPI Enumeration Date: | 05/27/2015 |
| NPI Last Update Date: | 11/12/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332B00000X |
| License Number: | NOT REQUIRED |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| 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 |