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General NPI Number Information
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NPI Number | 1063695633
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Entity Type | Organization
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Legal Business Name | ITALY SHOES AND BOUTIQUE
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Dates
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Enumeration Date | 12/06/2007
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Last Update Date | 12/06/2007
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Provider Practice Location Address
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Address Line | 11815 SOUTH ST
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City | CERRITOS
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State | CA
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Zip | 90703-6825
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Country | US
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Telephone | 562-860-4634
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Fax | 562-860-5109
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Provider Business Mailing Address
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Address Line | 11815 SOUTH ST
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City | CERRITOS
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State | CA
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Zip | 90703-6825
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Country | US
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Telephone | 562-860-4634
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Fax | 562-860-5109
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. SANDY SOO CHUN
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Credential |
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Telephone | 562-860-4634
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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