Provider Demographics
NPI:1316125214
Name:SAMUEL WEISBERG PROSTHETICS LLC
Entity type:Organization
Organization Name:SAMUEL WEISBERG PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/OWNER/CPO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISBERG
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:505-248-0303
Mailing Address - Street 1:1018 COAL AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106
Mailing Address - Country:US
Mailing Address - Phone:505-248-0303
Mailing Address - Fax:505-248-1611
Practice Address - Street 1:1018 COAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-248-0303
Practice Address - Fax:505-248-1611
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAMUEL WEISBERG PROSTHETICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-04
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT6249Medicaid
NMT6249Medicaid