Provider Demographics
NPI:1235345612
Name:SAMPSON'S PROSTHETIC LABORATORY INC
Entity Type:Organization
Organization Name:SAMPSON'S PROSTHETIC LABORATORY INC
Other - Org Name:HANGER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER CONTRACT ANALYST III
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGELINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-961-2102
Mailing Address - Street 1:PO BOX 650846
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:178 WASHINGTON AVENUE EXT STE 102
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5323
Practice Address - Country:US
Practice Address - Phone:518-374-6011
Practice Address - Fax:518-393-3292
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANGER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-15
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03003394Medicaid
NY0351430003Medicare NSC
NY0351430003OtherPTAN