Provider Demographics
NPI:1902208945
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:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CPO
Authorized Official - Phone:413-735-1223
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 1:516 CAREW ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2330
Practice Address - Country:US
Practice Address - Phone:413-735-1223
Practice Address - Fax:413-735-1214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier