MEDICARE: COBBLER'S CORNER SHOE REPAIR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)

General Provider Information

NPI Number	:	1013124510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COBBLER'S CORNER SHOE REPAIR

Provider Business Mailing Address
First Line	:	663 HINCHEY RD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14624-2830
Country	:	US
Telephone Number	:	585-235-3382
Fax Number	:

Provider Business Practice Location Address
First Line	:	376 JEFFERSON RD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14623-2439
Country	:	US
Telephone Number	:	585-475-1951
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MICHAEL FANTAUZZO
Credential	:
Telephone Number	:	585-475-1951

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	08/22/2020

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