Provider Demographics
NPI:1124167309
Name:NORTHERN ORTHOPEDIC LABORATORY, INC.
Entity type:Organization
Organization Name:NORTHERN ORTHOPEDIC LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:315-782-9079
Mailing Address - Street 1:600 E GENESEE ST
Mailing Address - Street 2:SUITE 114
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3130
Mailing Address - Country:US
Mailing Address - Phone:315-476-3831
Mailing Address - Fax:315-476-3908
Practice Address - Street 1:600 E GENESEE ST
Practice Address - Street 2:SUITE 114
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3130
Practice Address - Country:US
Practice Address - Phone:315-476-3831
Practice Address - Fax:315-476-3908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02128389Medicaid
NY02128389Medicaid