Provider Demographics
NPI:1003866088
Name:FRESNO PROSTHETIC INC
Entity Type:Organization
Organization Name:FRESNO PROSTHETIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:ABC CP003235
Authorized Official - Phone:559-225-2400
Mailing Address - Street 1:4832 N 1ST ST
Mailing Address - Street 2:STE 102
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-0524
Mailing Address - Country:US
Mailing Address - Phone:559-225-2400
Mailing Address - Fax:559-225-3529
Practice Address - Street 1:4832 N 1ST ST
Practice Address - Street 2:STE 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-0524
Practice Address - Country:US
Practice Address - Phone:559-225-2400
Practice Address - Fax:559-225-3529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherEIN
CA6069720001Medicare NSC