Provider Demographics
NPI:1699874743
Name:PROSTHETICS BY NELSON
Entity type:Organization
Organization Name:PROSTHETICS BY NELSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:716-894-6666
Mailing Address - Street 1:2959 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-2653
Mailing Address - Country:US
Mailing Address - Phone:716-894-6666
Mailing Address - Fax:716-894-1858
Practice Address - Street 1:310 FAIRMONT AVENUE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-4776
Practice Address - Country:US
Practice Address - Phone:716-488-1001
Practice Address - Fax:716-488-1034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02720116Medicaid
NY0403320005Medicare ID - Type Unspecified