=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962650739
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSQUEHANNA VALLEY PROSTHETICS & ORTHOTICS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2008
-----------------------------------------------------
Last Update Date | 09/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6850 LOWS RD SUITE 220
-----------------------------------------------------
City | BLOOMSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17815-8729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-387-1711
-----------------------------------------------------
Fax | 570-387-1766
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6850 LOWS RD SUITE 220
-----------------------------------------------------
City | BLOOMSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17815-8729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-387-1711
-----------------------------------------------------
Fax | 570-387-1766
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ PROSTHETIST
-----------------------------------------------------
Name | MR. FRANK T DOMINICK
-----------------------------------------------------
Credential | CP
-----------------------------------------------------
Telephone | 570-743-1414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 6000007253
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------