Organization
COUNTRY COBBLER, LTD.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MARK ALLEN MANTEY (DIABETIC SHOE PROGRAM FACILITATOR)
(910) 772-9994
Entity
Organization
Contact information
Practice address
3501 OLEANDER DR, SUITE 11, WILMINGTON, NC 28403-0824
(910) 772-9994
(910) 772-1262
Mailing address
3501 OLEANDER DR, SUITE 11, WILMINGTON, NC 28403-0824
(910) 772-9994
(910) 772-1262
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
00992
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7704409
—
NC
Enumeration date
04/05/2006
Last updated
09/18/2015
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