Country Cobbler, LTD.

Primary specialty

Prosthetic/Orthotic SupplierTaxonomy code 335E00000X

License

00992 Issued in NC

Legal business name

COUNTRY COBBLER, LTD.

Practice address

3501 Oleander Dr
Suite 11
Wilmington, NC 28403-0824

Phone

(910) 772-9994

Fax

(910) 772-1262

NPI assigned

Apr 5, 2006

Last updated

Sep 18, 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

Mr. Mark Allen Mantey

Title

Diabetic Shoe Program Facilitator

Phone

(910) 772-9994

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

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

{
    "created_epoch": "1144195200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1442534400000",
    "number": "1780646653",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3501 OLEANDER DR",
            "address_2": "SUITE 11",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284030824",
            "telephone_number": "910-772-9994",
            "fax_number": "910-772-1262"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3501 OLEANDER DR",
            "address_2": "SUITE 11",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284030824",
            "telephone_number": "910-772-9994",
            "fax_number": "910-772-1262"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTRY COBBLER, LTD.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-05",
        "last_updated": "2015-09-18",
        "status": "A",
        "authorized_official_last_name": "MANTEY",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "ALLEN",
        "authorized_official_title_or_position": "DIABETIC SHOE PROGRAM FACILITATOR",
        "authorized_official_telephone_number": "910-772-9994",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "335E00000X",
            "taxonomy_group": "",
            "desc": "Prosthetic/Orthotic Supplier",
            "state": "NC",
            "license": "00992",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7704409",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Prosthetic/Orthotic Supplier in Wilmington, NC
• Providers in Wilmington, NC by specialty
• Prosthetic/Orthotic Supplier in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 18, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.