Provider Demographics
NPI:1013093053
Name:PROTHOTIC LABORATORY, INC.
Entity Type:Organization
Organization Name:PROTHOTIC LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:QUIGG
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:631-753-4444
Mailing Address - Street 1:2023 NEW HWY
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-1103
Mailing Address - Country:US
Mailing Address - Phone:631-753-4444
Mailing Address - Fax:631-753-1874
Practice Address - Street 1:2035 LAKEVILLE RD STE 202
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1661
Practice Address - Country:US
Practice Address - Phone:516-427-7714
Practice Address - Fax:631-753-4451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0183030002Medicare NSC