Provider Demographics
NPI:1265677512
Name:METRO SHOE REPAIR
Entity Type:Organization
Organization Name:METRO SHOE REPAIR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGI
Authorized Official - Middle Name:
Authorized Official - Last Name:ITSHAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-847-1132
Mailing Address - Street 1:116-27 METROPOLITAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415
Mailing Address - Country:US
Mailing Address - Phone:718-847-1132
Mailing Address - Fax:
Practice Address - Street 1:116-27 METROPOLITAN AVENUE
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415
Practice Address - Country:US
Practice Address - Phone:718-847-1132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment