Organization
E. WAGNER'S SHOES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JERRY L. STOUT (OWNER)
(708) 771-4528
Entity
Organization
Contact information
Practice address
7379 NORTH AVE, RIVER FOREST, IL 60305-1230
(708) 771-4528
Mailing address
7379 NORTH AVE, RIVER FOREST, IL 60305-1230
(708) 771-4528
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
0887330001
IL
Other
Enumeration date
01/03/2007
Last updated
12/17/2008
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