Provider Demographics
NPI:1003812371
Name:KEYSTONE PROSTHETICS AND ORTHOTICS
Entity Type:Organization
Organization Name:KEYSTONE PROSTHETICS AND ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, CPO
Authorized Official - Phone:570-587-4110
Mailing Address - Street 1:231 NORTHERN BLVD
Mailing Address - Street 2:STE D
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-9189
Mailing Address - Country:US
Mailing Address - Phone:570-587-4110
Mailing Address - Fax:570-587-4145
Practice Address - Street 1:231 NORTHERN BLVD
Practice Address - Street 2:STE D
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-9189
Practice Address - Country:US
Practice Address - Phone:570-587-4110
Practice Address - Fax:570-587-4145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001610040000BMedicaid
PA1128100001Medicare ID - Type Unspecified