Provider Demographics
NPI:1235277336
Name:DELTA ORTHOPEDIC LAB., INC.
Entity Type:Organization
Organization Name:DELTA ORTHOPEDIC LAB., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GBOLAHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SASONA
Authorized Official - Suffix:
Authorized Official - Credentials:CPO, LPO
Authorized Official - Phone:201-222-7777
Mailing Address - Street 1:1010 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-3519
Mailing Address - Country:US
Mailing Address - Phone:201-222-7777
Mailing Address - Fax:201-222-7740
Practice Address - Street 1:1010 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-3519
Practice Address - Country:US
Practice Address - Phone:201-222-7777
Practice Address - Fax:201-222-7740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ45PO00000400225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3444601Medicaid
NJ3444601Medicaid