Provider Demographics
NPI: | 1710360201 |
---|---|
Name: | ADVANT ORTHOCARE |
Entity Type: | Organization |
Organization Name: | ADVANT ORTHOCARE |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | IGAL |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ILYAS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 718-428-4600 |
Mailing Address - Street 1: | 5847 FRANCIS LEWIS BLVD |
Mailing Address - Street 2: | SUITE 17 |
Mailing Address - City: | OAKLAND GARDENS |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 11364-1698 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 718-428-4600 |
Mailing Address - Fax: | 718-428-4611 |
Practice Address - Street 1: | 5847 FRANCIS LEWIS BLVD |
Practice Address - Street 2: | SUITE 17 |
Practice Address - City: | OAKLAND GARDENS |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11364-1698 |
Practice Address - Country: | US |
Practice Address - Phone: | 718-428-4600 |
Practice Address - Fax: | 718-428-4611 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2015-07-02 |
Last Update Date: | 2015-07-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 2019021 | 332B00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies |