Basic Information
| Provider Information | |||||||||
| NPI: | 1992175459 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - NORTHEAST, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 865109 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328865109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8446023960 | ||||||||
| FaxNumber: | 8132818461 | ||||||||
| Practice Location | |||||||||
| Address1: | 1645 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165055007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148758700 | ||||||||
| FaxNumber: | 8148758756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2015 | ||||||||
| LastUpdateDate: | 09/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | HARMS | ||||||||
| AuthorizedOfficialFirstName: | LANCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ORTHOTICS & PROSTHETICS | ||||||||
| AuthorizedOfficialTelephone: | 8148758700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - NORTHEAST, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
No ID Information.