Provider Demographics
NPI:1891964029
Name:LORELEI ORTHOTICS & PROSTHETICS, INC.
Entity type:Organization
Organization Name:LORELEI ORTHOTICS & PROSTHETICS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:KILCOMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:212-727-2011
Mailing Address - Street 1:19 W 21ST ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-6805
Mailing Address - Country:US
Mailing Address - Phone:212-727-2011
Mailing Address - Fax:212-727-0844
Practice Address - Street 1:200 VETERANS RD
Practice Address - Street 2:BUILDING A, GROUND FLOOR
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598-4130
Practice Address - Country:US
Practice Address - Phone:914-962-3814
Practice Address - Fax:212-727-0844
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LORELEI ORTHOTICS & PROSTHETICS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01091818Medicaid
NJ1046705Medicaid