Healthcare Provider Details

I. General information

NPI: 1669040960
Provider Name (Legal Business Name): PERFORMANCE ORTHOPEDIC DESIGN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 CONSTABLE ST FL 1
MALONE NY
12953-1324
US

IV. Provider business mailing address

7 OLD MILITARY RD
LAKE PLACID NY
12946-1614
US

V. Phone/Fax

Practice location:
  • Phone: 518-521-3257
  • Fax:
Mailing address:
  • Phone: 518-523-2419
  • Fax: 518-523-7192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JEFFREY L ERENSTONE
Title or Position: OWNER, CPO
Credential:
Phone: 518-523-2419