Provider Demographics
NPI:1912307992
Name:PRESQUE ISLE ORTHOTICS AND PROSTHETICS OF OHIO, LLC
Entity Type:Organization
Organization Name:PRESQUE ISLE ORTHOTICS AND PROSTHETICS OF OHIO, LLC
Other - Org Name:PRESQUE ISLE MEDICAL TECHNOLOGIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
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:216-371-0660
Mailing Address - Street 1:14055 CEDAR RD STE 107
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44118-3333
Mailing Address - Country:US
Mailing Address - Phone:216-371-0660
Mailing Address - Fax:
Practice Address - Street 1:3700 OAKTON ST STE 103
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-3407
Practice Address - Country:US
Practice Address - Phone:773-432-7616
Practice Address - Fax:773-432-7616
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESQUE ISLE ORTHOTICS AND PROSTHETICS OF OHIO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-27
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid