Provider Demographics
NPI:1750477444
Name:KEYSTONE PROSTHETICS AND ORTHOTICS, INC.
Entity Type:Organization
Organization Name:KEYSTONE PROSTHETICS AND ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:PT,CPO
Authorized Official - Phone:570-307-4191
Mailing Address - Street 1:334 MAIN STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:DICKSON CITY
Mailing Address - State:PA
Mailing Address - Zip Code:18519
Mailing Address - Country:US
Mailing Address - Phone:570-307-4191
Mailing Address - Fax:570-307-4195
Practice Address - Street 1:334 MAIN STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:DICKSON CITY
Practice Address - State:PA
Practice Address - Zip Code:18519
Practice Address - Country:US
Practice Address - Phone:570-307-4191
Practice Address - Fax:570-307-4195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016100400004Medicaid
PA1128100001Medicare NSC