Provider Demographics
NPI:1043613821
Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES-WEST,LLC
Entity Type:Organization
Organization Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES-WEST,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KANAS
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:813-281-7184
Mailing Address - Street 1:PO BOX 865109
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-5109
Mailing Address - Country:US
Mailing Address - Phone:844-602-3960
Mailing Address - Fax:813-281-8461
Practice Address - Street 1:909 S FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2625
Practice Address - Country:US
Practice Address - Phone:626-389-9411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES-WEST,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-07
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000150335E00000X
CA335E00000X, 335G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No335G00000XSuppliersMedical Foods Supplier