Provider Demographics
NPI:1104808716
Name:PRO-THOTICS TECHNOLOGY INC
Entity type:Organization
Organization Name:PRO-THOTICS TECHNOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:AFFENITA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-569-5562
Mailing Address - Street 1:285 SILLS RD
Mailing Address - Street 2:BUILDING 3 SUITE D
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4869
Mailing Address - Country:US
Mailing Address - Phone:631-569-5562
Mailing Address - Fax:631-569-5565
Practice Address - Street 1:285 SILLS RD
Practice Address - Street 2:BUILDING 3 SUITE D
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4869
Practice Address - Country:US
Practice Address - Phone:631-569-5562
Practice Address - Fax:631-569-5565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02631941Medicaid
NY02631941Medicaid