Provider Demographics
NPI:1053473959
Name:NORTHEAST PEDORTHICS AND DME LLC
Entity Type:Organization
Organization Name:NORTHEAST PEDORTHICS AND DME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPLE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANDONNET
Authorized Official - Suffix:
Authorized Official - Credentials:C PED
Authorized Official - Phone:401-383-4466
Mailing Address - Street 1:999 WARWICK AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-3646
Mailing Address - Country:US
Mailing Address - Phone:401-383-4466
Mailing Address - Fax:401-383-4598
Practice Address - Street 1:999 WARWICK AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-3646
Practice Address - Country:US
Practice Address - Phone:401-383-4466
Practice Address - Fax:401-383-4598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30762477Medicaid
RI3740001Medicaid
RI3740001Medicaid
4843740001Medicare ID - Type UnspecifiedREGION A