Provider Demographics
NPI:1760631089
Name:BUCKLE MY SHOE, LLC
Entity type:Organization
Organization Name:BUCKLE MY SHOE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-682-1821
Mailing Address - Street 1:4723 E DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-1012
Mailing Address - Country:US
Mailing Address - Phone:316-682-1821
Mailing Address - Fax:316-682-1005
Practice Address - Street 1:4723 E DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1012
Practice Address - Country:US
Practice Address - Phone:316-682-1821
Practice Address - Fax:316-682-1005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332900000XSuppliersNon-Pharmacy Dispensing Site
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS5554540001Medicare NSC