Provider Demographics
NPI:1861407561
Name:VAGABOND SHOES, INC.
Entity type:Organization
Organization Name:VAGABOND SHOES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELNHOFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-606-0163
Mailing Address - Street 1:1243 BEECHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-7261
Mailing Address - Country:US
Mailing Address - Phone:920-606-0163
Mailing Address - Fax:920-882-3988
Practice Address - Street 1:4760 INTEGRITY WAY
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8464
Practice Address - Country:US
Practice Address - Phone:920-882-3989
Practice Address - Fax:920-882-3988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier