Provider Demographics
NPI:1982993929
Name:RIVER STREET PEDORTHICS, INC.
Entity Type:Organization
Organization Name:RIVER STREET PEDORTHICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:MCFADDEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:570-820-3333
Mailing Address - Street 1:363 LAUREL STREET
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-3535
Mailing Address - Country:US
Mailing Address - Phone:570-820-3333
Mailing Address - Fax:570-820-3331
Practice Address - Street 1:363 LAUREL STREET
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-3535
Practice Address - Country:US
Practice Address - Phone:570-820-3333
Practice Address - Fax:570-820-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies