Provider Demographics
NPI:1982682134
Name:LALOMA THIRTY-NINE INC
Entity Type:Organization
Organization Name:LALOMA THIRTY-NINE INC
Other - Org Name:BREAK-N-BRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAROCCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-356-3730
Mailing Address - Street 1:PO BOX 1826
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422
Mailing Address - Country:US
Mailing Address - Phone:610-356-3730
Mailing Address - Fax:610-471-0736
Practice Address - Street 1:2004 SPROUL ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008
Practice Address - Country:US
Practice Address - Phone:610-356-3730
Practice Address - Fax:610-471-0736
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LALOMA THIRTY-NINE INC. (DBA BREAK-N-BRACE)
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-06
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030815330001Medicaid
PA0871990001Medicare NSC