Provider Demographics
NPI:1578699393
Name:KENDALL PROSTHETICS & ORTHOTICS, INC.
Entity type:Organization
Organization Name:KENDALL PROSTHETICS & ORTHOTICS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKSUMOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-502-5273
Mailing Address - Street 1:14221 SW 120TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-7291
Mailing Address - Country:US
Mailing Address - Phone:305-540-3220
Mailing Address - Fax:645-231-2080
Practice Address - Street 1:14221 SW 120TH ST STE 110
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-7291
Practice Address - Country:US
Practice Address - Phone:305-540-3220
Practice Address - Fax:645-231-2080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR5335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM2289OtherBLUE CROSS BLUE SHEILD
FL226307OtherAVMED HEALTH PLANS
FL951163600Medicaid
FL169843900OtherU.S. DEPT. OF LABOR OWCP
FL169843900OtherU.S. DEPT. OF LABOR OWCP
FLM2289OtherBLUE CROSS BLUE SHEILD
FL951163600Medicaid