Provider Demographics
NPI:1114479706
Name:PROSTHETIC TECHNOLOGY CENTER
Entity Type:Organization
Organization Name:PROSTHETIC TECHNOLOGY CENTER
Other - Org Name:TPC
Other - Org Type:Other Name
Authorized Official - Title/Position:LICENSED PROSTHETIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LIBER
Authorized Official - Last Name:MOSQUERA CASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:CP/LP
Authorized Official - Phone:562-373-8667
Mailing Address - Street 1:1700 N DIXIE HWY STE 107
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-1807
Mailing Address - Country:US
Mailing Address - Phone:562-373-8667
Mailing Address - Fax:855-611-8511
Practice Address - Street 1:1700 N DIXIE HWY STE 107
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-1807
Practice Address - Country:US
Practice Address - Phone:562-373-8667
Practice Address - Fax:855-611-8511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPRO 174335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier