Provider Demographics
NPI:1609891597
Name:MT MEDICAL, LLC
Entity Type:Organization
Organization Name:MT MEDICAL, LLC
Other - Org Name:COMFORT FOOTWEAR ETC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:TSVOK
Authorized Official - Suffix:
Authorized Official - Credentials:C-PED
Authorized Official - Phone:860-232-1868
Mailing Address - Street 1:208 PARK RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-2015
Mailing Address - Country:US
Mailing Address - Phone:860-232-1868
Mailing Address - Fax:860-761-2658
Practice Address - Street 1:208 PARK RD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-2015
Practice Address - Country:US
Practice Address - Phone:860-232-1868
Practice Address - Fax:860-761-2658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004214269Medicaid