Provider Demographics
NPI:1396938775
Name:PROGRESSIVE ORTHOTICS LTD
Entity type:Organization
Organization Name:PROGRESSIVE ORTHOTICS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CO BOCP
Authorized Official - Phone:631-732-5556
Mailing Address - Street 1:285 SILLS ROAD
Mailing Address - Street 2:SUITE 8C
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-447-3860
Mailing Address - Fax:631-447-6050
Practice Address - Street 1:285 SILLS RD
Practice Address - Street 2:SUITE 8C
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-447-3860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00615045Medicaid
NY00615045Medicaid