Provider Demographics
NPI:1306043625
Name:INNOVATIVE ORTHOTICS & PROSTHETICS, LLC
Entity Type:Organization
Organization Name:INNOVATIVE ORTHOTICS & PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOMB
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:561-296-2000
Mailing Address - Street 1:537 US HIGHWAY 1
Mailing Address - Street 2:SUITE 6
Mailing Address - City:NORTH PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-4903
Mailing Address - Country:US
Mailing Address - Phone:561-296-2000
Mailing Address - Fax:561-296-9912
Practice Address - Street 1:537 US HIGHWAY 1
Practice Address - Street 2:SUITE 6
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-4903
Practice Address - Country:US
Practice Address - Phone:561-296-2000
Practice Address - Fax:561-296-9912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR188222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032644500Medicaid
FLM2829OtherBCBSFL
FL032644500Medicaid