Provider Demographics
NPI:1205036142
Name:PERFORMANCE ORTHOPEDIC DESIGN, LLC
Entity Type:Organization
Organization Name:PERFORMANCE ORTHOPEDIC DESIGN, LLC
Other - Org Name:MOUNTAIN ORTHOTIC AND PROSTHETIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:ERENSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-523-2419
Mailing Address - Street 1:7 OLD MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:NY
Mailing Address - Zip Code:12946-1614
Mailing Address - Country:US
Mailing Address - Phone:518-523-2419
Mailing Address - Fax:518-523-7192
Practice Address - Street 1:7 OLD MILITARY RD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:NY
Practice Address - Zip Code:12946-1614
Practice Address - Country:US
Practice Address - Phone:518-523-2419
Practice Address - Fax:518-523-7192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02936501Medicaid
NY02936501Medicaid