Provider Demographics
NPI:1720441272
Name:SHORE PROSTHETICS AND ORTHOTICS LLC
Entity Type:Organization
Organization Name:SHORE PROSTHETICS AND ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SOLOMON
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIFETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-897-1141
Mailing Address - Street 1:844 RITCHIE HWY STE 202
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-4137
Mailing Address - Country:US
Mailing Address - Phone:410-897-1141
Mailing Address - Fax:866-294-9581
Practice Address - Street 1:9160 ESTATE THOMAS
Practice Address - Street 2:FORTRESS MALL UNIT K2032
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802-3641
Practice Address - Country:US
Practice Address - Phone:340-714-1009
Practice Address - Fax:866-294-9581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1-21556-1L335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI4299150002Medicare NSC