Provider Demographics
NPI:1316028848
Name:EMPIRE PROSTHETIC & ORTHOTIC CENTER
Entity Type:Organization
Organization Name:EMPIRE PROSTHETIC & ORTHOTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:F
Authorized Official - Last Name:HABEGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPO
Authorized Official - Phone:760-955-8855
Mailing Address - Street 1:16471 VICTOR ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-3942
Mailing Address - Country:US
Mailing Address - Phone:760-955-8855
Mailing Address - Fax:760-955-7799
Practice Address - Street 1:16471 VICTOR ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3942
Practice Address - Country:US
Practice Address - Phone:760-955-8855
Practice Address - Fax:760-955-7799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO02310335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXA0157280Medicaid
CAXA0157280Medicaid