1073569554 NPI number — PROSTHETIC & ORTHOTIC GROUP, INC

Table of content: (NPI 1073569554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073569554 NPI number — PROSTHETIC & ORTHOTIC GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROSTHETIC & ORTHOTIC GROUP, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073569554
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2669 MYRTLE AVE
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
SIGNAL HILL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90755-2745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-595-6445
Provider Business Mailing Address Fax Number:
562-424-3122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2669 MYRTLE AVE
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
SIGNAL HILL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-595-6445
Provider Business Practice Location Address Fax Number:
562-424-3122
Provider Enumeration Date:
05/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MARLOW
Authorized Official First Name:
SONIA
Authorized Official Middle Name:
Authorized Official Title or Position:
OPERATIONS DIRECTOR
Authorized Official Telephone Number:
562-595-6445

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GXC000190 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".