Provider Demographics
NPI:1770127540
Name:SUPREME ORTHO FITTING, LLC
Entity type:Organization
Organization Name:SUPREME ORTHO FITTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-885-2974
Mailing Address - Street 1:501 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-5427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:269A BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-2408
Practice Address - Country:US
Practice Address - Phone:973-885-2974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-04
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies