Provider Demographics
NPI:1225366792
Name:INNOVATIVE PROSTHETIC SOLUTIONS, INC
Entity Type:Organization
Organization Name:INNOVATIVE PROSTHETIC SOLUTIONS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:VANDERSEA
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:207-482-9874
Mailing Address - Street 1:110 MARGINAL WAY
Mailing Address - Street 2:#192
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2442
Mailing Address - Country:US
Mailing Address - Phone:207-482-9874
Mailing Address - Fax:
Practice Address - Street 1:120 PERCY HAWKES RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-4397
Practice Address - Country:US
Practice Address - Phone:207-482-9874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-21
Last Update Date:2009-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier