=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649940388
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BT ORTHOTIC LABS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2021
-----------------------------------------------------
Last Update Date | 09/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 184 E 70TH ST STE B1
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10021-5154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-470-3778
-----------------------------------------------------
Fax | 631-423-1550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 96 E MAIN ST UNIT 1
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-2816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-470-3778
-----------------------------------------------------
Fax | 631-423-1550
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO OWNER / DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | KATHRYN ANNE BETHEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-470-3778
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------