Provider Demographics
NPI:1558798355
Name:NUTMEG ORTHOTICS AND PROSTHETICS LLC
Entity Type:Organization
Organization Name:NUTMEG ORTHOTICS AND PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-488-1062
Mailing Address - Street 1:131 KENT RD # BUIDINGB
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-3485
Mailing Address - Country:US
Mailing Address - Phone:860-488-1062
Mailing Address - Fax:
Practice Address - Street 1:85 BARNES RD STE 302
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1832
Practice Address - Country:US
Practice Address - Phone:860-488-1062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-11
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7046370001Medicare NSC