Provider Demographics
NPI:1114507290
Name:MERCADO ORTHOTICS & PROSTHETICS
Entity Type:Organization
Organization Name:MERCADO ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:EDITH
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-923-7233
Mailing Address - Street 1:PO BOX 15108
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01115-5108
Mailing Address - Country:US
Mailing Address - Phone:413-923-7233
Mailing Address - Fax:413-750-9916
Practice Address - Street 1:399 FARMINGTON AVE
Practice Address - Street 2:SUITE LL1
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1937
Practice Address - Country:US
Practice Address - Phone:833-888-0057
Practice Address - Fax:413-750-9916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-12
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies