Provider Demographics
NPI:1225219587
Name:MODERN SHOE, INC.
Entity type:Organization
Organization Name:MODERN SHOE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:C
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-375-2711
Mailing Address - Street 1:350 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-4323
Mailing Address - Country:US
Mailing Address - Phone:801-375-2711
Mailing Address - Fax:801-371-0060
Practice Address - Street 1:350 W CENTER ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4323
Practice Address - Country:US
Practice Address - Phone:801-375-2711
Practice Address - Fax:801-371-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
6339340001Medicare NSC