Provider Demographics
NPI:1689843815
Name:LORELEI ORTHOTICS & PROSTHETICS, INC.
Entity Type:Organization
Organization Name:LORELEI ORTHOTICS & PROSTHETICS, INC.
Other - Org Name:NEW JERSEY OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:WESTLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:212-727-2011
Mailing Address - Street 1:19 W 21ST ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-6805
Mailing Address - Country:US
Mailing Address - Phone:212-727-2011
Mailing Address - Fax:212-727-0844
Practice Address - Street 1:63 LENOX AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1139
Practice Address - Country:US
Practice Address - Phone:201-226-0138
Practice Address - Fax:212-727-0844
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LORELEI ORTHOTICS & PROSTHETICS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-21
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01091818Medicaid
NJ1046705Medicaid