MEDICARE: BIDIANA EXTENSIONS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1396435731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIDIANA EXTENSIONS LLC

Provider Business Mailing Address
First Line	:	1324 FOREST AVE STE 104
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-2044
Country	:	US
Telephone Number	:	718-419-7399
Fax Number	:	631-256-1353

Provider Business Practice Location Address
First Line	:	1324 FOREST AVE STE 104
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-2044
Country	:	US
Telephone Number	:	718-419-7399
Fax Number	:	631-256-1353

Authorized Official
Title or Position	:	CEO
Name	:	ABIDEMI OMOBOLANLE OMOYEFA
Credential	:
Telephone Number	:	718-419-7399

Provider Enumeration Date	:	05/09/2023
Last Update Date	:	05/09/2023

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Directions to “BIDIANA EXTENSIONS LLC ” Practice Location

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