Provider Demographics
NPI:1104148741
Name:PACIFIC FOOTWEAR COMPANY, INC.
Entity type:Organization
Organization Name:PACIFIC FOOTWEAR COMPANY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-524-9656
Mailing Address - Street 1:10240 SW NIMBUS AVE
Mailing Address - Street 2:SUITE L1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-4358
Mailing Address - Country:US
Mailing Address - Phone:503-524-9656
Mailing Address - Fax:503-524-8397
Practice Address - Street 1:13660 N 94TH DR
Practice Address - Street 2:SUITE F-2
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4836
Practice Address - Country:US
Practice Address - Phone:623-302-9396
Practice Address - Fax:623-302-9397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-24
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5518680001Medicare NSC