Provider Demographics
NPI:1225430150
Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES- WEST, LLC
Entity Type:Organization
Organization Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES- WEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:DRAPER
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:801-536-3827
Mailing Address - Street 1:PO BOX 865109
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-5109
Mailing Address - Country:US
Mailing Address - Phone:844-602-3960
Mailing Address - Fax:813-281-8461
Practice Address - Street 1:1275 E FAIRFAX RD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-4324
Practice Address - Country:US
Practice Address - Phone:801-536-3820
Practice Address - Fax:801-536-3731
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES- WEST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier