Provider Demographics
NPI:1982697181
Name:INNOVATIVE ORTHOTICS & PROSTHETICS
Entity type:Organization
Organization Name:INNOVATIVE ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROSTHETIST
Authorized Official - Prefix:MR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALANT
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:914-592-6359
Mailing Address - Street 1:17 PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10607-2716
Mailing Address - Country:US
Mailing Address - Phone:914-592-6359
Mailing Address - Fax:914-592-0143
Practice Address - Street 1:17 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10607-2716
Practice Address - Country:US
Practice Address - Phone:914-592-6359
Practice Address - Fax:914-592-0143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01018717Medicaid
NY01018717Medicaid