Provider Demographics
NPI:1114948080
Name:KAWEAH ORTHOPEDIC & PROSTHETICS INC,.
Entity Type:Organization
Organization Name:KAWEAH ORTHOPEDIC & PROSTHETICS INC,.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BENCOMO
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:559-741-1300
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93279-0390
Mailing Address - Country:US
Mailing Address - Phone:559-741-1300
Mailing Address - Fax:559-741-1819
Practice Address - Street 1:2318 W SUNNYSIDE AVE STE 7
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-7266
Practice Address - Country:US
Practice Address - Phone:559-741-1300
Practice Address - Fax:559-741-1819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABL011033335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXA0141710Medicaid
CA5548110001Medicare ID - Type Unspecified