Provider Demographics
NPI:1851364764
Name:LIFESTYLE PROSTHETICS & ORTHOTICS, INC.
Entity Type:Organization
Organization Name:LIFESTYLE PROSTHETICS & ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:EMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:978-688-7900
Mailing Address - Street 1:27 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-1664
Mailing Address - Country:US
Mailing Address - Phone:978-688-7900
Mailing Address - Fax:978-688-7938
Practice Address - Street 1:27 CHARLES ST
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-1664
Practice Address - Country:US
Practice Address - Phone:978-688-7900
Practice Address - Fax:978-688-7938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MATA1E3F96683073335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1526341Medicaid
MAAA50699OtherHARVARD PILGRIM HEALTH CA
MA=========OtherTRICARE
MA5559290001Medicare ID - Type Unspecified