1104968288 NPI number — MEDSOURCE ORTHOTICS & PROSTHETICS

Table of content: (NPI 1104968288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104968288 NPI number — MEDSOURCE ORTHOTICS & PROSTHETICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDSOURCE 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:
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:
1104968288
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3636 N 3RD AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85013-3938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-395-3354
Provider Business Mailing Address Fax Number:
602-395-3361

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14821 N DEL WEBB BLVD
Provider Second Line Business Practice Location Address:
SUITE 24
Provider Business Practice Location Address City Name:
SUN CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-815-1001
Provider Business Practice Location Address Fax Number:
623-815-1441
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHARLES
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
801-255-5202

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)





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