Provider Demographics
NPI:1144342940
Name:ITALY SHOE LAB INC
Entity type:Organization
Organization Name:ITALY SHOE LAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDORTHIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CORNIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:PEDORTHIST
Authorized Official - Phone:813-645-5800
Mailing Address - Street 1:13521 MANGO BAY DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2336
Mailing Address - Country:US
Mailing Address - Phone:813-645-5800
Mailing Address - Fax:
Practice Address - Street 1:1201 1ST ST SW
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33570-5345
Practice Address - Country:US
Practice Address - Phone:813-770-5199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPED 76335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4914920001Medicare UPIN
FL4914920003Medicare UPIN
FL4914920002Medicare UPIN