MEDICARE: LSO ORTHOTICS, CO.

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	1437862	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1437862	OTHER	NY	DCA LICENSE

General Provider Information

NPI Number	:	1922353770
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LSO ORTHOTICS, CO.

Provider Business Mailing Address
First Line	:	3724 24TH ST STE 242
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-3553
Country	:	US
Telephone Number	:	718-606-2590
Fax Number	:

Provider Business Practice Location Address
First Line	:	3724 24TH ST STE 242
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-3553
Country	:	US
Telephone Number	:	718-606-2590
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DEMETRIOS SOTEROPOULOS
Credential	:
Telephone Number	:	917-921-3772

Provider Enumeration Date	:	07/18/2012
Last Update Date	:	09/24/2012

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