Provider Demographics
NPI:1104206499
Name:OTTO BOCK ORTHOPEDIC SERVICES LLC
Entity Type:Organization
Organization Name:OTTO BOCK ORTHOPEDIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATIONAL CONTRACT MGR.
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-806-2879
Mailing Address - Street 1:PO BOX 734949
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4949
Mailing Address - Country:US
Mailing Address - Phone:800-736-8276
Mailing Address - Fax:866-642-2302
Practice Address - Street 1:10643 KETTERING DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226
Practice Address - Country:US
Practice Address - Phone:800-736-8276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224P00000X, 332BC3200X, 335E00000X
NC02286332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02286OtherIN STATE NC HME LICENSURE
NC02396OtherAUSTIN NC HME LICENSURE
NC1104206499Medicaid