Organization
PROVOST SHOES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JOHN MARSHALL PROVOST C.PED (OWNER)
(570) 784-4645
Entity
Organization
Contact information
Practice address
225 COLUMBIA MALL DR, BLOOMSBURG, PA 17815-8368
(570) 784-4645
(570) 455-7704
Mailing address
225 COLUMBIA MALL DR, BLOOMSBURG, PA 17815-8368
(570) 784-4645
(570) 455-7704
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
4244780001
PA
Other
Enumeration date
02/25/2009
Last updated
02/25/2009
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