Organization
LISA E ROSTVOLD
Active
Other names
Blue Moon Shoes
Organization subpart
No
Provider details
NPI number
Authorized official
MS. LISA ELLEN ROSTVOLD CERTIFIED PEDORTHIST (OWNER)
(574) 267-5537
Entity
Organization
Contact information
Practice address
110 N BUFFALO ST, WARSAW, IN 46580-2754
(574) 267-5537
(574) 267-6165
Mailing address
110 N BUFFALO ST, WARSAW, IN 46580-2754
(574) 267-5537
(574) 267-6165
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
CPED2624
IN
Other
Enumeration date
02/14/2008
Last updated
06/19/2008
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