=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659557734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSQUEHANNA VALLEY PROSTHETICS & ORTHOTICS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2008
-----------------------------------------------------
Last Update Date | 02/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 W COLLEGE AVE SUITE A
-----------------------------------------------------
City | PLEASANT GAP
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16823-7401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-359-1244
-----------------------------------------------------
Fax | 814-359-1232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 243
-----------------------------------------------------
City | SHAMOKIN DAM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17876-0243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-743-1414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. FRANK DOMINICK III
-----------------------------------------------------
Credential | CP
-----------------------------------------------------
Telephone | 570-743-1414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 6000007083
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------