Provider Demographics
NPI:1467794123
Name:CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF NORTH CAROLINA, INC
Entity Type:Organization
Organization Name:CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF NORTH CAROLINA, INC
Other - Org Name:CENTER FOR ORTHOTIC AND PROSTHETIC CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:REG COMPLIANCE SPECIALIST 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 1:522 LIBERTY ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-1249
Mailing Address - Country:US
Mailing Address - Phone:315-218-6706
Mailing Address - Fax:
Practice Address - Street 1:475 IRVING AVE STE 216
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1558
Practice Address - Country:US
Practice Address - Phone:315-218-6706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03966492Medicaid
NY4120510007Medicare NSC