Organization
LAKE CITY SHOE REPAIR
Active
Other names
PARTNERSHIP
Organization subpart
No
Provider details
NPI number
Authorized official
WAYNE C JOHNSON CPED (SENIOR PARTNOR)
(208) 762-0797
Entity
Organization
Contact information
Practice address
3115 N GOVERNMENT WAY, #7, COEUR D ALENE, ID 83815-3790
(208) 762-0797
(208) 762-0791
Mailing address
3115 N GOVERNMENT WAY, #7, COEUR D ALENE, ID 83815-3790
(208) 762-0797
(208) 762-0791
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
NOT REQUIRED
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5127610001
PTAN
ID
Enumeration date
05/27/2015
Last updated
11/12/2015
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