| Organization Name: | PROVOST SHOES |
| NPI Number: | 1972743268 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JOHN MARSHALL PROVOST (OWNER) |
| Mailing Address: | 225 Columbia Mall Dr Bloomsburg |
| State: | PA US |
| Postal Code: | 178158368 |
| Phone Number: | 5707844645 |
| Fax Number: | 5704557704 |
| NPI Enumeration Date: | 02/25/2009 |
| NPI Last Update Date: | 02/25/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332B00000X |
| License Number: | 4244780001 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | PA |
| 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 |