Healthcare Provider Details

I. General information

NPI: 1457641094
Provider Name (Legal Business Name): VIVIANO CUSTOM SHOE COMPANY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2011
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 CANOGA AVE STE 12
CANOGA PARK CA
91304-5019
US

IV. Provider business mailing address

7801 CANOGA AVE STE 12
CANOGA PARK CA
91304-5019
US

V. Phone/Fax

Practice location:
  • Phone: 818-292-8250
  • Fax: 818-292-8690
Mailing address:
  • Phone: 818-292-8250
  • Fax: 818-292-8690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number101-697629
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number101-697629
License Number StateCA

VIII. Authorized Official

Name: MR. JOSEPH FRANK VIVIANO
Title or Position: PRESIDENT
Credential: CERTIFIED PEDORTHIST
Phone: 818-292-8250