Provider Demographics
NPI:1962542019
Name:FOOTWEAR BY DESIGN
Entity type:Organization
Organization Name:FOOTWEAR BY DESIGN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ECKENRODE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPED
Authorized Official - Phone:407-323-7441
Mailing Address - Street 1:1967 LONGWOOD LAKE MARY RD
Mailing Address - Street 2:SUITE 1001
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4673
Mailing Address - Country:US
Mailing Address - Phone:407-323-7441
Mailing Address - Fax:407-323-1964
Practice Address - Street 1:1967 LONGWOOD LAKE MARY RD
Practice Address - Street 2:SUITE 1001
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4673
Practice Address - Country:US
Practice Address - Phone:407-323-7441
Practice Address - Fax:407-323-1964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPED154332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5955580001Medicare NSC