Provider Demographics
NPI:1093350266
Name:EAST SIDE ORTHOTICS & PROSTHETICS, INC.
Entity Type:Organization
Organization Name:EAST SIDE ORTHOTICS & PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CLINICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:503-257-6623
Mailing Address - Street 1:91 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-5013
Mailing Address - Country:US
Mailing Address - Phone:503-970-8388
Mailing Address - Fax:503-257-6624
Practice Address - Street 1:91 MADISON ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-5013
Practice Address - Country:US
Practice Address - Phone:503-970-8388
Practice Address - Fax:503-257-6624
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTSIDE ORTHOTICS & PROSTHETICS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-12
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500778749Medicaid