Provider Demographics
NPI:1659557734
Name:SUSQUEHANNA VALLEY PROSTHETICS & ORTHOTICS, INC.
Entity Type:Organization
Organization Name:SUSQUEHANNA VALLEY PROSTHETICS & ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINICK
Authorized Official - Suffix:III
Authorized Official - Credentials:CP
Authorized Official - Phone:570-743-1414
Mailing Address - Street 1:PO BOX 243
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN DAM
Mailing Address - State:PA
Mailing Address - Zip Code:17876-0243
Mailing Address - Country:US
Mailing Address - Phone:570-743-1414
Mailing Address - Fax:
Practice Address - Street 1:550 W COLLEGE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PLEASANT GAP
Practice Address - State:PA
Practice Address - Zip Code:16823-7401
Practice Address - Country:US
Practice Address - Phone:814-359-1244
Practice Address - Fax:814-359-1232
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUSQUEHANNA VALLEY PROSTHETICS & ORTHOTICS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-18
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000007083335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2477665OtherAETNA
PA340622OtherHEALTH AMERICA
PA57492OtherGEISINGER HEALTH PLAN
PA0018173000002Medicaid
PA28389OtherDIMENSIONS
PA1511123OtherGATEWAY
PA39HA76OtherCAPITAL BLUE CROSS
PA57492OtherGEISINGER HEALTH PLAN
PA28389OtherDIMENSIONS