Provider Demographics
NPI:1548354590
Name:KMCPEDORTHICS INC
Entity type:Organization
Organization Name:KMCPEDORTHICS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRES
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CASTELLI
Authorized Official - Suffix:
Authorized Official - Credentials:CPED COF
Authorized Official - Phone:718-441-5621
Mailing Address - Street 1:92 HARTMAN HILL RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:718-441-5621
Mailing Address - Fax:718-441-5622
Practice Address - Street 1:8620 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421
Practice Address - Country:US
Practice Address - Phone:718-441-5621
Practice Address - Fax:718-441-5622
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KMCPEDORTHICS INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-03
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1148222Z00000X
335E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5511050001Medicare ID - Type Unspecified