Provider Demographics
NPI:1336537042
Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES- NORTHEAST, LLC
Entity type:Organization
Organization Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES- NORTHEAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ORTHOTICS & PROSTHETICS
Authorized Official - Prefix:MS
Authorized Official - First Name:CALLI
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:215-430-4096
Mailing Address - Street 1:PO BOX 947109
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-7109
Mailing Address - Country:US
Mailing Address - Phone:813-367-2876
Mailing Address - Fax:813-518-7659
Practice Address - Street 1:3551 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140
Practice Address - Country:US
Practice Address - Phone:215-430-4000
Practice Address - Fax:215-430-4027
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES- NORTHEAST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-05
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier