Provider Demographics
NPI:1659383032
Name:PROSTHETIC PROFESSIONALS, INC.
Entity Type:Organization
Organization Name:PROSTHETIC PROFESSIONALS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TULIO
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:718-748-4880
Mailing Address - Street 1:355 OVINGTON AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-1483
Mailing Address - Country:US
Mailing Address - Phone:718-748-4880
Mailing Address - Fax:718-748-4884
Practice Address - Street 1:355 OVINGTON AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-1483
Practice Address - Country:US
Practice Address - Phone:718-748-4880
Practice Address - Fax:718-748-4884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCPO02645332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02706090Medicaid
NY5460610001Medicare ID - Type Unspecified