Provider Demographics
NPI:1043328214
Name:TRIAD ORTHOTICS AND PEDORTHICS INC.
Entity Type:Organization
Organization Name:TRIAD ORTHOTICS AND PEDORTHICS INC.
Other - Org Name:TRIAD O&P
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:MANSFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:CO C PED
Authorized Official - Phone:336-712-4750
Mailing Address - Street 1:2419 LEWISVILLE CLEMMONS RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8977
Mailing Address - Country:US
Mailing Address - Phone:336-712-4750
Mailing Address - Fax:336-712-1056
Practice Address - Street 1:2419 LEWISVILLE CLEMMONS RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8976
Practice Address - Country:US
Practice Address - Phone:336-712-4750
Practice Address - Fax:336-712-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC045Y8OtherBCBS
802694OtherPARTNER'S
7887369OtherAETNA
NY03093634Medicaid
SCDM1188Medicaid
VA010072336Medicaid
NC7703603Medicaid
NC4297410001Medicare NSC