Provider Demographics
NPI:1609089523
Name:JEFFERSON PROSTHETIC & ORTHOTIC COMPANY, INC.
Entity Type:Organization
Organization Name:JEFFERSON PROSTHETIC & ORTHOTIC COMPANY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:C W
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:973-762-0780
Mailing Address - Street 1:120 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2103
Mailing Address - Country:US
Mailing Address - Phone:973-762-0780
Mailing Address - Fax:973-762-1480
Practice Address - Street 1:120 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-2103
Practice Address - Country:US
Practice Address - Phone:973-762-0780
Practice Address - Fax:973-762-1480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ45PO00002400335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0209180001Medicare NSC