MEDICARE: ITALY SHOE LAB, INC

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	335E00000X	Prosthetic/Orthotic Supplier	PED 76	FL

General Provider Information

NPI Number	:	1740302645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ITALY SHOE LAB, INC

Provider Business Mailing Address
First Line	:	13521 MANGO BAY DR
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-2336
Country	:	US
Telephone Number	:	813-645-5800
Fax Number	:

Provider Business Practice Location Address
First Line	:	9639 PALM RIVER RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-4433
Country	:	US
Telephone Number	:	813-744-5155
Fax Number	:

Authorized Official
Title or Position	:	PEDORTHIST
Name	:	JEFFREY JAMES CORNIELLO
Credential	:	PEDORTHIST
Telephone Number	:	813-645-5800

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	08/22/2020

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