Provider Demographics
NPI:1518013275
Name:ATLANTIC PROSTHETIC AND ORTHOTIC SERVICES
Entity Type:Organization
Organization Name:ATLANTIC PROSTHETIC AND ORTHOTIC SERVICES
Other - Org Name:ATLANTICPROCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN-PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:207-774-1002
Mailing Address - Street 1:1274 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2111
Mailing Address - Country:US
Mailing Address - Phone:207-774-1002
Mailing Address - Fax:207-774-9002
Practice Address - Street 1:1274 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2111
Practice Address - Country:US
Practice Address - Phone:207-774-1002
Practice Address - Fax:207-774-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
MECPO 1271335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME007654OtherBLUE CROSS & BLUE SHIELD
ME007654OtherBLUE CROSS & BLUE SHIELD