1962541912 NPI number — PREFERRED ORTHOTIC AND PROSTHETIC SERVICES INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962541912 NPI number — PREFERRED ORTHOTIC AND PROSTHETIC SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREFERRED ORTHOTIC AND PROSTHETIC SERVICES 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:
EVERGREEN PROSTHETICS AND ORTHOTICS
Provider Other Organization Name Type Code:
3
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:
1962541912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8880 SW NIMBUS AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97008-7111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-971-7272
Provider Business Mailing Address Fax Number:
971-727-3162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 S CEDAR ST STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-572-1282
Provider Business Practice Location Address Fax Number:
253-572-1175
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
O'NEILL
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
503-407-5408

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: 1962541912 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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