Healthcare Provider Details

I. General information

NPI: 1932194271
Provider Name (Legal Business Name): SUSQUEHANNA VALLEY PROSTHETICS & ORTHOTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 N OLD TRAIL
SHAMOKIN DAM PA
17876
US

IV. Provider business mailing address

PO BOX 243
SHAMOKIN DAM PA
17876
US

V. Phone/Fax

Practice location:
  • Phone: 570-743-1414
  • Fax: 570-743-5215
Mailing address:
  • Phone: 570-743-1414
  • Fax: 570-743-5215

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: MR. FRANK THOMAS DOMINICK III
Title or Position: OWNER CERTIFIED PROSTHETIST
Credential: CP
Phone: 570-743-1414