Provider Demographics
NPI:1992849434
Name:FOOT FORM SHOES, INC.
Entity type:Organization
Organization Name:FOOT FORM SHOES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:CLISSA
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED PEDORTHIST
Authorized Official - Phone:610-370-2323
Mailing Address - Street 1:3981 PERKIOMEN AVE
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19606-2718
Mailing Address - Country:US
Mailing Address - Phone:610-370-2323
Mailing Address - Fax:610-370-2932
Practice Address - Street 1:3981 PERKIOMEN AVE
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19606-2718
Practice Address - Country:US
Practice Address - Phone:610-370-2323
Practice Address - Fax:610-370-2932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0505800001Medicare NSC