1265440234 NPI number — PERFORMANCE PROSTHETIC ORTHOTIC CENTER

Table of content: (NPI 1265440234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265440234 NPI number — PERFORMANCE PROSTHETIC ORTHOTIC CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERFORMANCE PROSTHETIC ORTHOTIC CENTER
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:
PERFORMANCE PROSTHETICS AND ORTHOTICS SPECIALISTS
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:
1265440234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3256
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA MONICA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90408-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-829-2322
Provider Business Mailing Address Fax Number:
310-315-3634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2820 SANTA MONICA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90404-2410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-829-2322
Provider Business Practice Location Address Fax Number:
310-315-3634
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RAPPOPORT
Authorized Official First Name:
ALBERT
Authorized Official Middle Name:
FLOYD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-829-2322

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  43027 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: GXC000450 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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