Organization
TRI CITY SHOES LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RANDY DUNHAM (OWNER)
(270) 651-8071
Entity
Organization
Contact information
Practice address
105 ROGERS RD, GLASGOW, KY 42141-1601
(270) 651-8071
Mailing address
105 ROGERS RD, GLASGOW, KY 42141-1601
(270) 651-8071
Taxonomy
Speciality
Code
Description
License number
State
332BC3200X
Customized Equipment (DME)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000577778
BC/BS
KY
05
—
90006255
—
KY
Enumeration date
07/11/2005
Last updated
10/28/2008
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