Healthcare Provider Details

I. General information

NPI: 1902208945
Provider Name (Legal Business Name): PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES-NORTHEAST,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 CAREW ST
SPRINGFIELD MA
01104-2330
US

IV. Provider business mailing address

PO BOX 947109
ATLANTA GA
30394-7109
US

V. Phone/Fax

Practice location:
  • Phone: 413-735-1223
  • Fax: 413-735-1214
Mailing address:
  • Phone: 813-367-2876
  • Fax: 813-518-7659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateMA

VIII. Authorized Official

Name: MR. BROCK MCCONKEY
Title or Position: MANAGER
Credential: MS, CPO
Phone: 413-735-1223