Provider Demographics
NPI:1093193765
Name:PRO-THOTICSTECHNOLOGY, INC
Entity Type:Organization
Organization Name:PRO-THOTICSTECHNOLOGY, INC
Other - Org Name:PROTHOTICS HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:AFFENITA
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:877-776-8400
Mailing Address - Street 1:285 SILLS RD
Mailing Address - Street 2:BLDG 3 STE D
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4869
Mailing Address - Country:US
Mailing Address - Phone:877-776-8400
Mailing Address - Fax:877-366-5492
Practice Address - Street 1:714 BROADWAY
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-3402
Practice Address - Country:US
Practice Address - Phone:877-776-8400
Practice Address - Fax:877-366-5492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ45PO00002800335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier