=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942293253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC ORTHOPEDIC LABORATORY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2005
-----------------------------------------------------
Last Update Date | 08/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 ROUTE 66
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12534-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-828-2333
-----------------------------------------------------
Fax | 518-828-1350
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 ROUTE 66
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12534-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-828-2333
-----------------------------------------------------
Fax | 518-828-1350
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JOHN FRANCIS HOFFERT JR.
-----------------------------------------------------
Credential | CO/BOCP
-----------------------------------------------------
Telephone | 518-828-2333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------