Healthcare Provider Details

I. General information

NPI: 1639245640
Provider Name (Legal Business Name): PEDORTHIC CONCEPTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 ATLANTIC CITY BLVD
BEACHWOOD NJ
08722
US

IV. Provider business mailing address

145 ATLANTIC CITY BLVD
BEACHWOOD NJ
08722
US

V. Phone/Fax

Practice location:
  • Phone: 732-341-6262
  • Fax: 732-341-5464
Mailing address:
  • Phone: 732-341-6262
  • Fax: 732-341-5464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name: MRS. PATRICIA DEQUEIROZ
Title or Position: OFFICE MGR
Credential:
Phone: 732-341-6262