Provider Demographics
NPI:1306912787
Name:SECOND SOLE SHOE REPAIR
Entity type:Organization
Organization Name:SECOND SOLE SHOE REPAIR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:MOHLER
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-664-0770
Mailing Address - Street 1:99 E CITY LINE AVE
Mailing Address - Street 2:SECOND SOLE SHOE REPAIR BALA CYNWYD SHOPPING CTR
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004
Mailing Address - Country:US
Mailing Address - Phone:610-664-0770
Mailing Address - Fax:
Practice Address - Street 1:99 E CITY LINE AVE
Practice Address - Street 2:SECOND SOLE SHOE REPAIR BALA CYNWYD SHOPPING CTR
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004
Practice Address - Country:US
Practice Address - Phone:610-664-0770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
0972070001Medicare ID - Type Unspecified