Provider Demographics
NPI:1669713467
Name:PRESQUE ISLE ORTHOTICS AND PROSTHETICS OF OHIO, LLC
Entity type:Organization
Organization Name:PRESQUE ISLE ORTHOTICS AND PROSTHETICS OF OHIO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SOLOMON
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIFETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-681-8658
Mailing Address - Street 1:2101 RICHMOND RD STE 1000
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-1390
Mailing Address - Country:US
Mailing Address - Phone:216-371-0660
Mailing Address - Fax:866-536-2954
Practice Address - Street 1:718 HORTON DR
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-3009
Practice Address - Country:US
Practice Address - Phone:301-681-8658
Practice Address - Fax:866-536-2954
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESQUE ISLE ORTHOTICS AND PROSTHETICS OF OHIO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-05
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD052595200Medicaid