Provider Demographics
NPI:1871250605
Name:MEDCAP GLAM
Entity Type:Organization
Organization Name:MEDCAP GLAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MINGO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:718-650-9109
Mailing Address - Street 1:1969A PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-2439
Mailing Address - Country:US
Mailing Address - Phone:718-650-9109
Mailing Address - Fax:
Practice Address - Street 1:1969A PALMER AVE
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-2439
Practice Address - Country:US
Practice Address - Phone:718-650-9109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-29
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier