Provider Demographics
NPI:1225637028
Name:REACH ORTHOTIC & PROSTHETIC SERVICE, INC.
Entity Type:Organization
Organization Name:REACH ORTHOTIC & PROSTHETIC SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-595-9800
Mailing Address - Street 1:11747 JEFFERSON AVE STE 5A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1999
Mailing Address - Country:US
Mailing Address - Phone:175-759-5980
Mailing Address - Fax:
Practice Address - Street 1:6251 E VIRGINIA BEACH BLVD STE 135
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2824
Practice Address - Country:US
Practice Address - Phone:757-586-3255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REACH ORTHOTIC & PROSTHETIC SERVICE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009190902Medicaid