Provider Demographics
NPI:1629199906
Name:FEDERICO, GREGORY C (ORTHOTIC FITTER)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:FEDERICO
Suffix:
Gender:M
Credentials:ORTHOTIC FITTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 NEW WAVERLY PL
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-7406
Mailing Address - Country:US
Mailing Address - Phone:919-233-2060
Mailing Address - Fax:919-233-2959
Practice Address - Street 1:580 NEW WAVERLY PL
Practice Address - Street 2:SUITE 140
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-7406
Practice Address - Country:US
Practice Address - Phone:919-233-2060
Practice Address - Fax:919-233-2959
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC17052174400000X, 225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Not Answered225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter