Provider Demographics
NPI:1063564367
Name:LILBURN SHOE REPAIR & PEDORTHICS INC
Entity type:Organization
Organization Name:LILBURN SHOE REPAIR & PEDORTHICS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:LEANDRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-931-0823
Mailing Address - Street 1:2605 SIMS CREST CT
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-4161
Mailing Address - Country:US
Mailing Address - Phone:770-891-3418
Mailing Address - Fax:
Practice Address - Street 1:4760 LAWRENCEVILLE HWY NW
Practice Address - Street 2:SUITE C-1
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3858
Practice Address - Country:US
Practice Address - Phone:770-931-0823
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9914332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAL937OtherKAISER PERMANENTE ID
GA0941660001Medicare NSC