Provider Demographics
NPI:1871840447
Name:PRESQUE ISLE ORTHOTICS AND PROSTHETICS OF OHIO, LLC
Entity Type:Organization
Organization Name:PRESQUE ISLE ORTHOTICS AND PROSTHETICS OF OHIO, LLC
Other - Org Name:PRESQUE ISLE MEDICAL TECHNOLOGIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:SOLOMON
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIFETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-371-0660
Mailing Address - Street 1:14055 CEDAR RD STE 107
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44118-3333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14055 CEDAR RD STE 107
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44118-3333
Practice Address - Country:US
Practice Address - Phone:216-371-0660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0860433-00Medicaid
OH0084932Medicaid