Provider Demographics
NPI:1811238611
Name:JAG ORTHOTICS & PROSTHETICS INC
Entity Type:Organization
Organization Name:JAG ORTHOTICS & PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GRIGORIY
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDKHOROV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-863-4969
Mailing Address - Street 1:8408 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8408 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7339
Practice Address - Country:US
Practice Address - Phone:917-863-4969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-05
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6800710001OtherMEDICARE PTAN
NY6800710001OtherMEDICARE PTAN