Provider Demographics
NPI:1992175459
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:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:BETANCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-875-8895
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 1:1645 W 8TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-5007
Practice Address - Country:US
Practice Address - Phone:814-875-8700
Practice Address - Fax:814-875-8756
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - NORTHEAST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-28
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier