Provider Demographics
NPI:1902935901
Name:LAURA'S CORSET SHOPPE INC.
Entity Type:Organization
Organization Name:LAURA'S CORSET SHOPPE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:V
Authorized Official - Last Name:TRIVOLI
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:818-241-5616
Mailing Address - Street 1:232 N BRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2610
Mailing Address - Country:US
Mailing Address - Phone:818-241-5616
Mailing Address - Fax:
Practice Address - Street 1:232 N BRAND BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2610
Practice Address - Country:US
Practice Address - Phone:818-241-5616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17087789332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0660840001Medicare UPIN