Provider Demographics
NPI:1639245640
Name:PEDORTHIC CONCEPTS INC
Entity Type:Organization
Organization Name:PEDORTHIC CONCEPTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEQUEIROZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-341-6262
Mailing Address - Street 1:145 ATLANTIC CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08722
Mailing Address - Country:US
Mailing Address - Phone:732-341-6262
Mailing Address - Fax:732-341-5464
Practice Address - Street 1:145 ATLANTIC CITY BLVD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08722
Practice Address - Country:US
Practice Address - Phone:732-341-6262
Practice Address - Fax:732-341-5464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ62714OtherAMERIGROUP
NJ7830505Medicaid
NJ62714OtherAMERIGROUP