Provider Demographics
NPI:1346667763
Name:POSITIVE IMAGE PROSTHETICS AND ORTHOTICS, INC
Entity Type:Organization
Organization Name:POSITIVE IMAGE PROSTHETICS AND ORTHOTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:LPO/CPO
Authorized Official - Phone:912-354-7500
Mailing Address - Street 1:5202 WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6230
Mailing Address - Country:US
Mailing Address - Phone:912-354-7500
Mailing Address - Fax:912-354-7887
Practice Address - Street 1:933 ELMA G MILES PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-8072
Practice Address - Country:US
Practice Address - Phone:912-354-7500
Practice Address - Fax:912-354-7887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA28335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1986Medicaid
GA000844698AMedicaid