Provider Demographics
NPI:1306082193
Name:THE SHOE TRAVELER DIABETIC FOOTWEAR AND MEDICAL SUPPLIES LLC
Entity type:Organization
Organization Name:THE SHOE TRAVELER DIABETIC FOOTWEAR AND MEDICAL SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIGLIACCIO
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED PEDORTHIST
Authorized Official - Phone:732-462-1005
Mailing Address - Street 1:647 WINTERBERRY BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-5344
Mailing Address - Country:US
Mailing Address - Phone:732-462-1005
Mailing Address - Fax:732-276-2369
Practice Address - Street 1:1214 ROUTE 9 S
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:NJ
Practice Address - Zip Code:07731-3329
Practice Address - Country:US
Practice Address - Phone:732-462-1005
Practice Address - Fax:732-276-2369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-28
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJCERTIFIED PEDORTHIST335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0244414Medicaid
NJ0244414Medicaid