Organization
DIABETIC SHOE SOURCE
Active
Organization
DIABETIC SHOE SOURCE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
AMY LUZAICH CFTS (PRESIDENT)
(763) 757-8086
Entity
Organization
Contact information
Practice address
2121 CLIFF DR STE 118, EAGAN, MN 55122-3431
(763) 757-8086
(763) 862-4797
Mailing address
2121 CLIFF DR STE 118, EAGAN, MN 55122-3431
(763) 757-8086
(763) 862-4797
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
520052200
—
MN
01
—
786A6DI
BCBS
MN
Enumeration date
01/23/2007
Last updated
10/21/2021
Update your record
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