Provider Demographics
NPI:1235144619
Name:MUNGER PROSTHETICS AND ORTHOTICS, INC
Entity Type:Organization
Organization Name:MUNGER PROSTHETICS AND ORTHOTICS, INC
Other - Org Name:TREVOR DALE MUNGER, CPO/MUNGER PROSTHETICS AND ORTHOTICS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:MUNGER
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:907-743-9991
Mailing Address - Street 1:5701 LAKE OTIS PKWY STE 400
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1778
Mailing Address - Country:US
Mailing Address - Phone:907-743-9991
Mailing Address - Fax:907-743-9992
Practice Address - Street 1:5701 LAKE OTIS PKWY STE 400
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-1778
Practice Address - Country:US
Practice Address - Phone:907-743-9991
Practice Address - Fax:907-743-9992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECPO 1700335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPO4651Medicaid
AK5636800001Medicare ID - Type Unspecified