1043328214 NPI number — TRIAD ORTHOTICS AND PEDORTHICS INC.

Table of content: (NPI 1043328214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043328214 NPI number — TRIAD ORTHOTICS AND PEDORTHICS INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRIAD ORTHOTICS AND PEDORTHICS 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:
6
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:
1043328214
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2419 LEWISVILLE CLEMMONS RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
CLEMMONS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27012-8977
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-712-4750
Provider Business Mailing Address Fax Number:
336-712-1056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2419 LEWISVILLE CLEMMONS RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
CLEMMONS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27012-8976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-712-4750
Provider Business Practice Location Address Fax Number:
336-712-1056
Provider Enumeration Date:
08/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANSFIELD
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
336-712-4750

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 045Y8 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 802694 . This is a "PARTNER'S" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7887369 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 03093634 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: DM1188 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010072336 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7703603 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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