Provider Demographics
NPI:1093223752
Name:ORTIZ, MIRANDA
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CEO
Mailing Address - Street 1:60138A FLOYD AVE
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98433-1591
Mailing Address - Country:US
Mailing Address - Phone:917-574-7759
Mailing Address - Fax:
Practice Address - Street 1:60138A FLOYD AVE
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98433-1591
Practice Address - Country:US
Practice Address - Phone:917-574-7759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management