Healthcare Provider Details

I. General information

NPI: 1093870743
Provider Name (Legal Business Name): PEDORTHIC TECHNOLOGIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2006
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 PARK AVE
CRANSTON RI
02905-1241
US

IV. Provider business mailing address

285 PARK AVE
CRANSTON RI
02905-1241
US

V. Phone/Fax

Practice location:
  • Phone: 401-780-0590
  • Fax: 401-780-0591
Mailing address:
  • Phone: 401-780-0590
  • Fax: 401-780-0591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ERIC PALMER
Title or Position: OWNER PRESIDENT
Credential:
Phone: 401-780-0590