Provider Demographics
NPI:1396920559
Name:YANG SHOE CORP. DBA JACOBUS SHOES
Entity type:Organization
Organization Name:YANG SHOE CORP. DBA JACOBUS SHOES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:YANG
Authorized Official - Middle Name:SON
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:201-567-3333
Mailing Address - Street 1:101 W PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2635
Mailing Address - Country:US
Mailing Address - Phone:201-567-3333
Mailing Address - Fax:201-567-3084
Practice Address - Street 1:101 W PALISADE AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2635
Practice Address - Country:US
Practice Address - Phone:201-567-3333
Practice Address - Fax:201-567-3084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ21096222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0136000Medicaid
NJ5925660001Medicare NSC