Provider Demographics
NPI:1588638803
Name:WYOMING VALLEY PROSTHETICS AND ORTHOTICS
Entity Type:Organization
Organization Name:WYOMING VALLEY PROSTHETICS AND ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANTE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOLINO
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:570-283-3835
Mailing Address - Street 1:300 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:SWOYERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18704
Mailing Address - Country:US
Mailing Address - Phone:570-283-3835
Mailing Address - Fax:570-283-3805
Practice Address - Street 1:300 AVENUE A
Practice Address - Street 2:
Practice Address - City:SWOYERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18704
Practice Address - Country:US
Practice Address - Phone:570-283-3835
Practice Address - Fax:570-283-3805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011636190003Medicaid
206119OtherBLUE CROSS
0230650001Medicare ID - Type Unspecified