Provider Demographics
NPI:1659639037
Name:CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF NORTH CAROLINA, INC
Entity Type:Organization
Organization Name:CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF NORTH CAROLINA, INC
Other - Org Name:CENTER FOR ORTHOTIC AND PROSTHETIC CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:REG COMPLIANCE SPECIALIST III
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGELINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-961-2102
Mailing Address - Street 1:1141 BROADWAY ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14904-2542
Mailing Address - Country:US
Mailing Address - Phone:607-215-0847
Mailing Address - Fax:607-767-6852
Practice Address - Street 1:1141 BROADWAY ST
Practice Address - Street 2:SUITE 6
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14904-2542
Practice Address - Country:US
Practice Address - Phone:607-215-0847
Practice Address - Fax:607-767-6852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2019-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04392247Medicaid
NY4120510006Medicare NSC