Provider Demographics
NPI:1033112636
Name:OREGON PEDORTHIC SERVICES
Entity Type:Organization
Organization Name:OREGON PEDORTHIC SERVICES
Other - Org Name:ARCHFITTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RODRICK
Authorized Official - Middle Name:FORD
Authorized Official - Last Name:STOCKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-491-1723
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-0154
Mailing Address - Country:US
Mailing Address - Phone:503-491-1723
Mailing Address - Fax:503-489-0706
Practice Address - Street 1:9932 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4474
Practice Address - Country:US
Practice Address - Phone:503-491-1723
Practice Address - Fax:503-489-0706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR335E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR207923Medicaid
OR=========OtherBLUE CROSS BLUE SHIELD
OR207923Medicaid
OR1070450001Medicare ID - Type Unspecified