Provider Demographics
NPI:1508954157
Name:EASTERN CRANIAL AFFILIATES, LLC
Entity Type:Organization
Organization Name:EASTERN CRANIAL AFFILIATES, LLC
Other - Org Name:INFINITE TECHNOLOGIES ORTHOTICS & PROSTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:TERPENNING
Authorized Official - Suffix:
Authorized Official - Credentials:CO, FAAOP
Authorized Official - Phone:703-807-5899
Mailing Address - Street 1:10523 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030
Mailing Address - Country:US
Mailing Address - Phone:703-807-5899
Mailing Address - Fax:703-807-1183
Practice Address - Street 1:10523 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030
Practice Address - Country:US
Practice Address - Phone:703-807-5899
Practice Address - Fax:703-807-1183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009190121Medicaid
VA288615OtherANTHEM
VAH933OtherBCBS
VA009190121Medicaid