Lake City Shoe Repair

Primary specialty

Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X

License

NOT REQUIRED Issued in ID

Legal business name

LAKE CITY SHOE REPAIR

Practice address

3115 N Government Way
#7
Coeur D Alene, ID 83815-3790

Phone

(208) 762-0797

Fax

(208) 762-0791

NPI assigned

May 27, 2015

Last updated

Nov 12, 2015By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Wayne C Johnson, CPEDNPI 1083785760

Title

Senior Partnor

Phone

(208) 762-0797

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• PARTNERSHIP Other name

Medicare fee-for-service enrollment

Enrolled in ID

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Wayne Clair Johnson

  • Durable Medical Equipment & Medical Supplies
  • Coeur d'Alene, ID
  • NPI 1083785760
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1432684800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1447286400000",
    "number": "1346629029",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3115 N GOVERNMENT WAY",
            "address_2": "#7",
            "city": "COEUR D ALENE",
            "state": "ID",
            "postal_code": "838153790",
            "telephone_number": "208-762-0797",
            "fax_number": "208-762-0791"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3115 N GOVERNMENT WAY",
            "address_2": "#7",
            "city": "COEUR D ALENE",
            "state": "ID",
            "postal_code": "838153790",
            "telephone_number": "208-762-0797",
            "fax_number": "208-762-0791"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE CITY SHOE REPAIR",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-05-27",
        "last_updated": "2015-11-12",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "WAYNE",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "SENIOR PARTNOR",
        "authorized_official_telephone_number": "208-762-0797",
        "authorized_official_credential": "CPED"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "ID",
            "license": "NOT REQUIRED",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PTAN",
            "identifier": "5127610001",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PARTNERSHIP",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Lake City Center, Inc.
• Lake City Dental
• Lake City Dental Specialties, PC
• Lake City Medical Investors, LLC (Life Care Center of Coeur D'Alene)
• Lake City Physical Therapy P a
• Lake City Surgeons PLLC
• Lakeside Eyecare
• Lakeside Holistic Health, PLLC
• Lakeside Pediatric & Adolescent Medicine, PLLC
• Lakeview Dental

• Durable Medical Equipment & Medical Supplies in Coeur d'Alene, ID
• Providers in Coeur d'Alene, ID by specialty
• Durable Medical Equipment & Medical Supplies in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 12, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.