Healthcare Provider Details

I. General information

NPI: 1962455873
Provider Name (Legal Business Name): ITALY SHOE LAB, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16621 HWY 301 S #107
WIMAUMA FL
33598
US

IV. Provider business mailing address

13521 MANGO BAY DR
RIVERVIEW FL
33579-2336
US

V. Phone/Fax

Practice location:
  • Phone: 813-645-5800
  • Fax: 813-641-0319
Mailing address:
  • Phone: 813-645-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberNO PED 76
License Number StateFL

VIII. Authorized Official

Name: JEFFREY M CORNIELLO
Title or Position: VICE-PRESIDENT
Credential: CPED
Phone: 813-645-5800