1285640979 NPI number — PRECISION ORTHOTICS & PROSTHETICS INC

Table of content: (NPI 1285640979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285640979 NPI number — PRECISION ORTHOTICS & PROSTHETICS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRECISION ORTHOTICS & PROSTHETICS 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:
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:
1285640979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7143 SEVILLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90255-4905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-388-5847
Provider Business Mailing Address Fax Number:
213-388-5848

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7143 SEVILLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90255-4905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-388-5847
Provider Business Practice Location Address Fax Number:
213-388-5848
Provider Enumeration Date:
08/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
YI
Authorized Official First Name:
KWON
Authorized Official Middle Name:
CHAE
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
213-388-5847

Provider Taxonomy Codes

  • Taxonomy code: 224P00000X ; 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: ZZZ655562 . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: XB0023570 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".