=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902208945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES-NORTHEAST,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2014
-----------------------------------------------------
Last Update Date | 04/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 516 CAREW ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01104-2330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-735-1223
-----------------------------------------------------
Fax | 413-735-1214
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 947109
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30394-7109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-367-2876
-----------------------------------------------------
Fax | 813-518-7659
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. BROCK MCCONKEY
-----------------------------------------------------
Credential | MS, CPO
-----------------------------------------------------
Telephone | 413-735-1223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------