Provider Demographics
NPI:1932364668
Name:SCIOTO SHOE MART INC
Entity type:Organization
Organization Name:SCIOTO SHOE MART INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/ C.PED
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED PEDORTHIST
Authorized Official - Phone:740-389-5775
Mailing Address - Street 1:206 JAMES WAY
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-5818
Mailing Address - Country:US
Mailing Address - Phone:740-389-5775
Mailing Address - Fax:740-389-1269
Practice Address - Street 1:206 JAMES WAY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-5818
Practice Address - Country:US
Practice Address - Phone:740-389-5775
Practice Address - Fax:740-389-1269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5134670002Medicare NSC