Provider Demographics
NPI:1871586883
Name:GREEN PROSTHETICS & ORTHOTICS, LLC
Entity type:Organization
Organization Name:GREEN PROSTHETICS & ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RAKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-774-1085
Mailing Address - Street 1:2241 PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-2954
Mailing Address - Country:US
Mailing Address - Phone:814-833-2311
Mailing Address - Fax:814-833-5202
Practice Address - Street 1:2241 PENINSULA DR
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-2954
Practice Address - Country:US
Practice Address - Phone:814-833-2311
Practice Address - Fax:814-833-5202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BC3200X
PA6000005987335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02254635OtherNY
OH0322029OtherOH
PA1007721900001Medicaid
OH0322029OtherOH