Provider Demographics
NPI:1992598023
Name:DIABETIC SHOE CLINIC LLC
Entity type:Organization
Organization Name:DIABETIC SHOE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:KISER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-644-3815
Mailing Address - Street 1:652 SPRING MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-9443
Mailing Address - Country:US
Mailing Address - Phone:606-644-3815
Mailing Address - Fax:
Practice Address - Street 1:2611 GREENBO BLVD
Practice Address - Street 2:
Practice Address - City:FLATWOODS
Practice Address - State:KY
Practice Address - Zip Code:41139-1830
Practice Address - Country:US
Practice Address - Phone:606-644-3815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-22
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment