1982608493 NPI number — EASTSIDE ORTHOTICS AND PROSTHETICS, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982608493 NPI number — EASTSIDE ORTHOTICS AND PROSTHETICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTSIDE ORTHOTICS AND PROSTHETICS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982608493
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 COMMERCE DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
RIVERHEAD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11901-3174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-727-8735
Provider Business Mailing Address Fax Number:
631-727-6834

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
622 W 168TH ST
Provider Second Line Business Practice Location Address:
VC333
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-305-3275
Provider Business Practice Location Address Fax Number:
212-305-5927
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FLYNN
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
631-727-8735

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01052611 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com