Provider Demographics
NPI:1851355994
Name:GIBRALTAR ORTHOTICS INC
Entity Type:Organization
Organization Name:GIBRALTAR ORTHOTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT ABC CERTIFIED OFFICE
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCISCENTE
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:845-620-1188
Mailing Address - Street 1:91 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:10965
Mailing Address - Country:US
Mailing Address - Phone:845-620-1188
Mailing Address - Fax:845-620-1180
Practice Address - Street 1:91 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:NY
Practice Address - Zip Code:10965
Practice Address - Country:US
Practice Address - Phone:845-620-1188
Practice Address - Fax:845-620-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0000036680225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00978845Medicaid
0288690001Medicare ID - Type Unspecified