Provider Demographics
NPI:1104859248
Name:PROSTHETIC DEVELOPMENT AND RESEARCH, INC.
Entity Type:Organization
Organization Name:PROSTHETIC DEVELOPMENT AND RESEARCH, INC.
Other - Org Name:SAN JUAN PROSTHETICS AND ORTHOTICS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:970-259-9258
Mailing Address - Street 1:1 MERCADO ST
Mailing Address - Street 2:STE. 203
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7300
Mailing Address - Country:US
Mailing Address - Phone:970-259-9258
Mailing Address - Fax:970-385-7262
Practice Address - Street 1:1 MERCADO ST
Practice Address - Street 2:STE. 203
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7300
Practice Address - Country:US
Practice Address - Phone:970-259-9258
Practice Address - Fax:970-385-7262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1428335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08002149Medicaid
CO0693120002Medicare ID - Type Unspecified