Provider Demographics
NPI:1093717365
Name:ORTHOTIC SPECIALISTS, INC
Entity Type:Organization
Organization Name:ORTHOTIC SPECIALISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTIN
Authorized Official - Suffix:
Authorized Official - Credentials:CO CO(C)
Authorized Official - Phone:602-263-1010
Mailing Address - Street 1:2650 E MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-3658
Mailing Address - Country:US
Mailing Address - Phone:602-263-1010
Mailing Address - Fax:602-263-7473
Practice Address - Street 1:2650 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008
Practice Address - Country:US
Practice Address - Phone:602-263-1010
Practice Address - Fax:602-263-7473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ07619391X335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ723032OtherAHCCCS
AZAZ0278680OtherBCBSAZ
AZAZ0278680OtherBCBSAZ
AZ206418OtherARIZONA MEDICAL NETWORK
AZ723032OtherAHCCCS