1669040960 NPI number — PERFORMANCE ORTHOPEDIC DESIGN, LLC

Table of content: (NPI 1669040960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669040960 NPI number — PERFORMANCE ORTHOPEDIC DESIGN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERFORMANCE ORTHOPEDIC DESIGN, LLC
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:
MOUNTAIN ORTHOTIC & PROSTHETIC SERVICES
Provider Other Organization Name Type Code:
3
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:
1669040960
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 OLD MILITARY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE PLACID
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12946-1614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-523-2419
Provider Business Mailing Address Fax Number:
518-523-7192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 CONSTABLE ST FL 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALONE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12953-1324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-521-3257
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2021

Additional Information

Authorized Official

Authorized Official Last Name:
ERENSTONE
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER, CPO
Authorized Official Telephone Number:
518-523-2419

Provider Taxonomy Codes

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

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





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