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General NPI Number Information
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NPI Number | 1962455873
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Entity Type | Organization
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Legal Business Name | ITALY SHOE LAB, INC
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Dates
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Enumeration Date | 05/19/2006
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Last Update Date | 02/27/2008
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Provider Practice Location Address
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Address Line | 16621 HWY 301 S #107
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City | WIMAUMA
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State | FL
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Zip | 33598
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Country | US
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Telephone | 813-645-5800
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Fax | 813-641-0319
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Provider Business Mailing Address
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Address Line | 13521 MANGO BAY DR
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City | RIVERVIEW
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State | FL
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Zip | 33579-2336
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Country | US
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Telephone | 813-645-5800
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Fax |
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Authorized Official
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Title or Position | VICE-PRESIDENT
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Name | JEFFREY M CORNIELLO
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Credential | CPED
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Telephone | 813-645-5800
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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 | NO PED 76
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License Number State | FL
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