Provider Demographics
NPI:1699965780
Name:WISE FOOTWEAR, LLC
Entity type:Organization
Organization Name:WISE FOOTWEAR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:R
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:LPO
Authorized Official - Phone:419-236-1367
Mailing Address - Street 1:PO BOX 569
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-0569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1008 BELLEFONTAINE AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804
Practice Address - Country:US
Practice Address - Phone:419-236-1367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies