Provider Demographics
NPI:1760606974
Name:PINE TREE ORTHOPEDIC LAB INC.
Entity Type:Organization
Organization Name:PINE TREE ORTHOPEDIC LAB INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MACDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-897-5558
Mailing Address - Street 1:175 PARK ST
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE FALLS
Mailing Address - State:ME
Mailing Address - Zip Code:04254-4125
Mailing Address - Country:US
Mailing Address - Phone:207-897-5558
Mailing Address - Fax:207-897-1117
Practice Address - Street 1:175 PARK ST
Practice Address - Street 2:
Practice Address - City:LIVERMORE FALLS
Practice Address - State:ME
Practice Address - Zip Code:04254-4125
Practice Address - Country:US
Practice Address - Phone:207-897-5558
Practice Address - Fax:207-897-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME6229880001Medicare NSC