Provider Demographics
NPI:1861772782
Name:EAST COAST ORTHOTIC & PROSTHETIC CORP
Entity type:Organization
Organization Name:EAST COAST ORTHOTIC & PROSTHETIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BENENATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-392-2229
Mailing Address - Street 1:75 BURT DR
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-5701
Mailing Address - Country:US
Mailing Address - Phone:631-254-5577
Mailing Address - Fax:631-254-5550
Practice Address - Street 1:1400 PORTLAND AVE
Practice Address - Street 2:SUITE 52
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3014
Practice Address - Country:US
Practice Address - Phone:585-266-1333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST COAST ORTHOTIC & PROSTHETIC CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-23
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01749013Medicaid