Provider Demographics
NPI:1639675309
Name:ORTHOTICPRO,INC.
Entity Type:Organization
Organization Name:ORTHOTICPRO,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGOS
Authorized Official - Suffix:
Authorized Official - Credentials:BOCP,BOCO
Authorized Official - Phone:917-256-9049
Mailing Address - Street 1:PO BOX 1195
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-0916
Mailing Address - Country:US
Mailing Address - Phone:917-256-9049
Mailing Address - Fax:
Practice Address - Street 1:380 N BROADWAY APT C2
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-2064
Practice Address - Country:US
Practice Address - Phone:917-256-9049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC50803335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier