1568678936 NPI number — SAMPSON'S PROSTHETIC LABORATORY INC

Table of content: (NPI 1568678936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568678936 NPI number — SAMPSON'S PROSTHETIC LABORATORY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMPSON'S PROSTHETIC LABORATORY 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:
6
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:
1568678936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 650846
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75265-0846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5010 STATE HIGHWAY 30 STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMSTERDAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12010-7532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-374-6011
Provider Business Practice Location Address Fax Number:
518-393-3292
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIERNAN
Authorized Official First Name:
DIANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
PROVIDER CONTRACT ANALYST III
Authorized Official Telephone Number:
714-961-2102

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: 03003409 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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