Provider Demographics
NPI:1619193976
Name:IMPERIAL SHOE STORE CO INC
Entity Type:Organization
Organization Name:IMPERIAL SHOE STORE CO INC
Other - Org Name:IMPERIAL SHOES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP GEN MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:MARMORA
Authorized Official - Suffix:JR
Authorized Official - Credentials:C PED
Authorized Official - Phone:201-333-0419
Mailing Address - Street 1:516 WEST SIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-1516
Mailing Address - Country:US
Mailing Address - Phone:201-333-0419
Mailing Address - Fax:201-333-8087
Practice Address - Street 1:516 WEST SIDE AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-1516
Practice Address - Country:US
Practice Address - Phone:201-333-0419
Practice Address - Fax:201-333-8087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5517702Medicaid
NJ5517702Medicaid