Provider Demographics
NPI:1356567234
Name:BALLOWS SHOES INC
Entity type:Organization
Organization Name:BALLOWS SHOES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:GERVON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-788-2857
Mailing Address - Street 1:308 MILL STREET
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:PA
Mailing Address - Zip Code:19007-4811
Mailing Address - Country:US
Mailing Address - Phone:215-788-2857
Mailing Address - Fax:215-788-2857
Practice Address - Street 1:308 MILL STREET
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:PA
Practice Address - Zip Code:19007-4811
Practice Address - Country:US
Practice Address - Phone:215-788-2857
Practice Address - Fax:215-788-2857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6000000704Medicaid
PA6000000704Medicaid