Provider Demographics
NPI:1699748244
Name:STAFFORD LABS ORTHOTICS AND PROSTHETICS, INC.
Entity type:Organization
Organization Name:STAFFORD LABS ORTHOTICS AND PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:845-692-5227
Mailing Address - Street 1:PO BOX 1004
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924
Mailing Address - Country:US
Mailing Address - Phone:845-692-5227
Mailing Address - Fax:845-692-5244
Practice Address - Street 1:189 MONHAGEN AVE.
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940
Practice Address - Country:US
Practice Address - Phone:845-692-5227
Practice Address - Fax:845-692-5244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01478986Medicaid
NJ7830602Medicaid
NY01478986Medicaid