Provider Demographics
NPI:1114930765
Name:CONCOURSE ORTHOTIC AND PROSTHETIC LAB
Entity Type:Organization
Organization Name:CONCOURSE ORTHOTIC AND PROSTHETIC LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALTAGRACIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:305-362-6962
Mailing Address - Street 1:3750 W 16TH AVE
Mailing Address - Street 2:SUITE 404
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4654
Mailing Address - Country:US
Mailing Address - Phone:305-362-6962
Mailing Address - Fax:305-362-4424
Practice Address - Street 1:3750 W 16TH AVE
Practice Address - Street 2:SUITE 404
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4654
Practice Address - Country:US
Practice Address - Phone:305-362-6962
Practice Address - Fax:305-362-4424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5376660001Medicare NSC