Provider Demographics
NPI:1124209747
Name:TRIAD ORTHOTICS & PROSTHETICS
Entity Type:Organization
Organization Name:TRIAD ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:828-327-8777
Mailing Address - Street 1:1065 13TH ST SE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-4165
Mailing Address - Country:US
Mailing Address - Phone:828-327-8777
Mailing Address - Fax:828-327-8771
Practice Address - Street 1:1065 13TH ST SE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-4165
Practice Address - Country:US
Practice Address - Phone:828-327-8777
Practice Address - Fax:828-327-8771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704624Medicaid
NC5751560001Medicare NSC