Organization
CONCOURSE SURGICAL SPORT SUPPLY, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
NIDIA PENA (MANAGER)
(212) 569-2635
Entity
Organization
Contact information
Practice address
5049 BROADWAY, NEW YORK, NY 10034-1131
(212) 569-2635
(212) 569-2639
Mailing address
8 EDGEWOOD DR, ORANGEBURG, NY 10962-1604
(212) 569-2635
(212) 569-2639
Taxonomy
Speciality
Code
Description
License number
State
332BC3200X
Customized Equipment (DME)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01785982
—
NY
Enumeration date
08/14/2006
Last updated
10/05/2020
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