Provider Demographics
NPI:1114306891
Name:NORTHWEST ORTHOTICS & PROSTHETICS
Entity Type:Organization
Organization Name:NORTHWEST ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,BOCO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-377-3433
Mailing Address - Street 1:1675 N FREEDOM BLVD STE 12C
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6940
Mailing Address - Country:US
Mailing Address - Phone:801-377-3433
Mailing Address - Fax:
Practice Address - Street 1:642 KIRBY LN STE 103
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-5753
Practice Address - Country:US
Practice Address - Phone:801-377-3433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier