Organization
PROVOST SHOES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN M PROVOST C. PED (OWNER)
(570) 455-7704
Entity
Organization
Contact information
Practice address
25 LAUREL MALL, HAZLETON, PA 18202-1201
(570) 455-7704
(570) 455-7704
Mailing address
25 LAUREL MALL, HAZLETON, PA 18202-1201
(570) 455-7704
(570) 455-7704
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
4244780002
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
A08009797
MEDICARE EDI BILLING NUMB
—
Enumeration date
11/26/2007
Last updated
12/05/2007
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