=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245522085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DONNELLY ORTHOTIC AND PROSTHETIC SYSTEMS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2011
-----------------------------------------------------
Last Update Date | 05/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 FAIR HARBOUR PL
-----------------------------------------------------
City | NEW LONDON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06320-4710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-605-1725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 FAIR HARBOUR PL
-----------------------------------------------------
City | NEW LONDON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06320-4710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-605-1725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MR. PATRICK DONNELLY
-----------------------------------------------------
Credential | CPO
-----------------------------------------------------
Telephone | 203-605-1725
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------