Provider Demographics
NPI:1447497730
Name:812 PROCTOR AVE
Entity type:Organization
Organization Name:812 PROCTOR AVE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:HU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-866-1668
Mailing Address - Street 1:812 PROCTOR AVE
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2205
Mailing Address - Country:US
Mailing Address - Phone:888-866-1668
Mailing Address - Fax:888-866-1668
Practice Address - Street 1:812 PROCTOR AVE
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2205
Practice Address - Country:US
Practice Address - Phone:888-866-1668
Practice Address - Fax:888-866-1668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies