1558545418 NPI number — DYNAMIC PROSTHETIC & ORTHOTIC

Table of content: (NPI 1558545418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558545418 NPI number — DYNAMIC PROSTHETIC & ORTHOTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC PROSTHETIC & ORTHOTIC
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:
1558545418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 WESTSIDE DR NW
Provider Second Line Business Mailing Address:
SUITE 306
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37312-3699
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-478-5093
Provider Business Mailing Address Fax Number:
423-622-2400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 WESTSIDE DR NW
Provider Second Line Business Practice Location Address:
SUITE 306
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37312-3699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-478-5093
Provider Business Practice Location Address Fax Number:
423-622-2400
Provider Enumeration Date:
12/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
AMY
Authorized Official Middle Name:
ROOKS
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
423-622-2000

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)

  • Identifier: 4033710 . This is a "BLUECARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1454227 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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