1669713467 NPI number — PRESQUE ISLE ORTHOTICS AND PROSTHETICS OF OHIO, LLC

Table of content: (NPI 1669713467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669713467 NPI number — PRESQUE ISLE ORTHOTICS AND PROSTHETICS OF OHIO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESQUE ISLE ORTHOTICS AND PROSTHETICS OF OHIO, 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:
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:
1669713467
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 RICHMOND RD STE 1000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEACHWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44122-1390
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-371-0660
Provider Business Mailing Address Fax Number:
866-536-2954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
718 HORTON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SILVER SPRING
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20902-3009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-681-8658
Provider Business Practice Location Address Fax Number:
866-536-2954
Provider Enumeration Date:
03/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HEIFETZ
Authorized Official First Name:
SOLOMON
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
301-681-8658

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; 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: 052595200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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