Provider Demographics
NPI:1326058058
Name:EASTERN VA ORTHOTICS & PROSTHETICS, INC
Entity Type:Organization
Organization Name:EASTERN VA ORTHOTICS & PROSTHETICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMIN
Authorized Official - Prefix:MISS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-850-2835
Mailing Address - Street 1:PO BOX 3511
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23663-0511
Mailing Address - Country:US
Mailing Address - Phone:757-850-2835
Mailing Address - Fax:757-850-3409
Practice Address - Street 1:13394 CHESAPEAKE PL
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:VA
Practice Address - Zip Code:23314-3388
Practice Address - Country:US
Practice Address - Phone:757-850-2835
Practice Address - Fax:757-850-3409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAC12887222Z00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1326058058OtherUNITED HEALTHCARE
VA009190384Medicaid
VA1326058058OtherHUMANA
VA073161OtherBLUE CROSS & BLUE SHIELD