Provider Demographics
NPI:1134128366
Name:THE ORTHOPEDIC STORE
Entity Type:Organization
Organization Name:THE ORTHOPEDIC STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:HARIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-366-2990
Mailing Address - Street 1:PO BOX 792590
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78279-2590
Mailing Address - Country:US
Mailing Address - Phone:210-366-2990
Mailing Address - Fax:210-491-8002
Practice Address - Street 1:4455 S PADRE ISLAND DR
Practice Address - Street 2:SUITE 14
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-5101
Practice Address - Country:US
Practice Address - Phone:361-814-9600
Practice Address - Fax:361-814-9602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0053879332B00000X
TX000115335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1283180002Medicare NSC