Provider Demographics
NPI:1003046137
Name:ADVANCED ORTHOTIC DESIGNS
Entity Type:Organization
Organization Name:ADVANCED ORTHOTIC DESIGNS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:LATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-226-1110
Mailing Address - Street 1:105 S STATE ST
Mailing Address - Street 2:602
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5419
Mailing Address - Country:US
Mailing Address - Phone:801-226-1110
Mailing Address - Fax:
Practice Address - Street 1:105 S STATE ST
Practice Address - Street 2:602
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5419
Practice Address - Country:US
Practice Address - Phone:801-226-1110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12269678-002-STC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies