Healthcare Provider Details

I. General information

NPI: 1851355994
Provider Name (Legal Business Name): GIBRALTAR ORTHOTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 E CENTRAL AVE
PEARL RIVER NY
10965
US

IV. Provider business mailing address

91 E CENTRAL AVE
PEARL RIVER NY
10965
US

V. Phone/Fax

Practice location:
  • Phone: 845-620-1188
  • Fax: 845-620-1180
Mailing address:
  • Phone: 845-620-1188
  • Fax: 845-620-1180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number0000036680
License Number State

VIII. Authorized Official

Name: MR. DANIEL SCISCENTE
Title or Position: VICE PRESIDENT ABC CERTIFIED OFFICE
Credential: C.O.
Phone: 845-620-1188