Provider Demographics
NPI:1205008117
Name:LONG ISLAND COMFORT SHOES AND PEDORTHIC SERVICES
Entity Type:Organization
Organization Name:LONG ISLAND COMFORT SHOES AND PEDORTHIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PEDORTHIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:CELESTINO
Authorized Official - Suffix:
Authorized Official - Credentials:C PED
Authorized Official - Phone:631-476-9717
Mailing Address - Street 1:403 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1843
Mailing Address - Country:US
Mailing Address - Phone:631-476-9717
Mailing Address - Fax:631-476-9718
Practice Address - Street 1:403 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1843
Practice Address - Country:US
Practice Address - Phone:631-476-9717
Practice Address - Fax:631-476-9718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
4983710001Medicare NSC