Provider Demographics
NPI:1942293253
Name:DYNAMIC ORTHOPEDIC LABORATORY
Entity Type:Organization
Organization Name:DYNAMIC ORTHOPEDIC LABORATORY
Other - Org Name:JOHN F HOFFERT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:HOFFERT
Authorized Official - Suffix:JR
Authorized Official - Credentials:CO/BOCP
Authorized Official - Phone:518-828-2333
Mailing Address - Street 1:320 ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-3429
Mailing Address - Country:US
Mailing Address - Phone:518-828-2333
Mailing Address - Fax:518-828-1350
Practice Address - Street 1:320 ROUTE 66
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-3429
Practice Address - Country:US
Practice Address - Phone:518-828-2333
Practice Address - Fax:518-828-1350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00867670Medicaid
NY000400980001OtherBSOF NORTHWEST NEW YORK
NY10014666OtherCAP. DIST. PHY. HEALTH PL
0321690001Medicare ID - Type Unspecified