Provider Demographics
NPI:1962650739
Name:SUSQUEHANNA VALLEY PROSTHETICS & ORTHOTICS, INC.
Entity Type:Organization
Organization Name:SUSQUEHANNA VALLEY PROSTHETICS & ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROSTHETIST
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:T
Authorized Official - Last Name:DOMINICK
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:570-743-1414
Mailing Address - Street 1:6850 LOWS RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-8729
Mailing Address - Country:US
Mailing Address - Phone:570-387-1711
Mailing Address - Fax:570-387-1766
Practice Address - Street 1:6850 LOWS RD
Practice Address - Street 2:SUITE 220
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-8729
Practice Address - Country:US
Practice Address - Phone:570-387-1711
Practice Address - Fax:570-387-1766
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUSQUEHANNA VALLEY PROSTHETICS & ORTHOTICS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000007253335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA39HA76OtherKEYSTONE HEALTH PLAN
PA2477665OtherAETNA
PA1511123OtherGEISINGER HEALTH PLAN
PA28389OtherDIMENSIONS
PA39HA76OtherCAPITAL BLUE CROSS
PA116173OtherHEALTH AMERICA
PA0018173000003Medicaid
PASU206824OtherHIGHMARK BLUE SHIELD
PA28389OtherDIMENSIONS