Healthcare Provider Details

I. General information

NPI: 1255668737
Provider Name (Legal Business Name): ORTHO SHOES CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10032 QUEENS BLVD
FOREST HILLS NY
11375-2748
US

IV. Provider business mailing address

10032 QUEENS BLVD
FOREST HILLS NY
11375-2748
US

V. Phone/Fax

Practice location:
  • Phone: 917-304-6657
  • Fax:
Mailing address:
  • Phone: 917-304-6657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberCPED 3003
License Number StateDE

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. GABRIYEL ADZHIASHVILI
Title or Position: PRESIDENT
Credential: CPED
Phone: 917-304-6657