=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699192476
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN REHABILITATION TECHNOLOGIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2014
-----------------------------------------------------
Last Update Date | 03/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1180 LINCOLN AVE SUITE 4
-----------------------------------------------------
City | HOLBROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11741-2285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-360-6400
-----------------------------------------------------
Fax | 631-360-6449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1180 LINCOLN AVE SUITE 4
-----------------------------------------------------
City | HOLBROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11741-2285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-360-6400
-----------------------------------------------------
Fax | 631-360-6449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILLIAM MARK SCHWING
-----------------------------------------------------
Credential | LPO CPO
-----------------------------------------------------
Telephone | 631-360-6400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------