Healthcare Provider Details

I. General information

NPI: 1336537042
Provider Name (Legal Business Name): PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES- NORTHEAST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 N BROAD ST
PHILADELPHIA PA
19140
US

IV. Provider business mailing address

PO BOX 947109
ATLANTA GA
30394-7109
US

V. Phone/Fax

Practice location:
  • Phone: 215-430-4000
  • Fax: 215-430-4027
Mailing address:
  • Phone: 813-367-2876
  • Fax: 813-518-7659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. CALLI CLARK
Title or Position: DIRECTOR OF ORTHOTICS & PROSTHETICS
Credential: CPO
Phone: 215-430-4096