1295979649 NPI number — NORTHWEST ORTHOTICS & PROSTHETICS

Table of content: (NPI 1295979649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295979649 NPI number — NORTHWEST ORTHOTICS & PROSTHETICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST ORTHOTICS & PROSTHETICS
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:
1295979649
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1675 N FREEDOM BLVD
Provider Second Line Business Mailing Address:
BLDG 12-C
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604-2540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-377-3433
Provider Business Mailing Address Fax Number:
801-377-4127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1988 W 930 N
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
PLEASANT GROVE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84062-4131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-763-4568
Provider Business Practice Location Address Fax Number:
801-763-0558
Provider Enumeration Date:
04/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HILL
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER / BOCO
Authorized Official Telephone Number:
801-377-3433

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  10230905-003-STC , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 820305315003 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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