Provider Demographics
NPI:1568846111
Name:FOOTPRINT ORTHOTICS LLC
Entity Type:Organization
Organization Name:FOOTPRINT ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COOWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-372-0707
Mailing Address - Street 1:2 ATRIUM CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-9019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 ATRIUM CT
Practice Address - Street 2:SUITE B
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-9019
Practice Address - Country:US
Practice Address - Phone:570-372-0707
Practice Address - Fax:570-372-0799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000008656332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment