Healthcare Provider Details

I. General information

NPI: 1952489163
Provider Name (Legal Business Name): PROGRESSIVE ORTHOTICS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 MIDDLE COUNTRY RD STE G
SELDEN NY
11784-2532
US

IV. Provider business mailing address

280 MIDDLE COUNTRY RD STE G
SELDEN NY
11784-2532
US

V. Phone/Fax

Practice location:
  • Phone: 631-732-5556
  • Fax: 631-732-0218
Mailing address:
  • Phone: 631-732-5556
  • Fax: 631-732-0218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. BRUCE S GOODMAN
Title or Position: CEO
Credential: CO BOCP
Phone: 631-732-5556