Healthcare Provider Details

I. General information

NPI: 1548354590
Provider Name (Legal Business Name): KMCPEDORTHICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8620 JAMAICA AVE
WOODHAVEN NY
11421
US

IV. Provider business mailing address

92 HARTMAN HILL RD
HUNTINGTON NY
11743
US

V. Phone/Fax

Practice location:
  • Phone: 718-441-5621
  • Fax: 718-441-5622
Mailing address:
  • Phone: 718-441-5621
  • Fax: 718-441-5622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number1148
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: KIM MARIE CASTELLI
Title or Position: OWNER PRES
Credential: CPED COF
Phone: 718-441-5621