Provider Demographics
NPI:1083671606
Name:ORTHOTIC PROSTHETIC DESIGN, LLC
Entity Type:Organization
Organization Name:ORTHOTIC PROSTHETIC DESIGN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CO, BOCO
Authorized Official - Phone:205-248-2193
Mailing Address - Street 1:1061 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-4035
Mailing Address - Country:US
Mailing Address - Phone:205-248-2193
Mailing Address - Fax:205-248-2195
Practice Address - Street 1:1061 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-4035
Practice Address - Country:US
Practice Address - Phone:205-248-2193
Practice Address - Fax:205-248-2195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL#51335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier