Provider Demographics
NPI:1063695633
Name:ITALY SHOES AND BOUTIQUE
Entity type:Organization
Organization Name:ITALY SHOES AND BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:SOO
Authorized Official - Last Name:CHUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-860-4634
Mailing Address - Street 1:11815 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-6825
Mailing Address - Country:US
Mailing Address - Phone:562-860-4634
Mailing Address - Fax:562-860-5109
Practice Address - Street 1:11815 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6825
Practice Address - Country:US
Practice Address - Phone:562-860-4634
Practice Address - Fax:562-860-5109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5489290001Medicare PIN