Provider Demographics
NPI:1962758714
Name:COUNTRY COBBLER, LTD.
Entity type:Organization
Organization Name:COUNTRY COBBLER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MONTEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-772-9994
Mailing Address - Street 1:1001 AIRPORT BLVD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-8935
Mailing Address - Country:US
Mailing Address - Phone:919-319-9799
Mailing Address - Fax:919-319-8985
Practice Address - Street 1:1001 AIRPORT BLVD
Practice Address - Street 2:SUITE 125
Practice Address - City:MORRISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27560-8935
Practice Address - Country:US
Practice Address - Phone:919-319-9799
Practice Address - Fax:919-319-8985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00992335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier