Provider Demographics
NPI:1316099310
Name:JOHNS ORTHOPEDIC & SHOE REPAIR LLC
Entity type:Organization
Organization Name:JOHNS ORTHOPEDIC & SHOE REPAIR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:URRUTIA
Authorized Official - Suffix:
Authorized Official - Credentials:C PED
Authorized Official - Phone:201-339-8750
Mailing Address - Street 1:929 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3050
Mailing Address - Country:US
Mailing Address - Phone:201-339-8750
Mailing Address - Fax:201-455-2606
Practice Address - Street 1:929 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3050
Practice Address - Country:US
Practice Address - Phone:201-339-8750
Practice Address - Fax:201-455-2606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8087202Medicaid
NJ0670030001Medicare NSC