Provider Demographics
NPI:1366467904
Name:PURI ORTHOPEDIC CENTER, INC.
Entity Type:Organization
Organization Name:PURI ORTHOPEDIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEATA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-243-0464
Mailing Address - Street 1:12830 HESPERIA ROAD, SUITE A
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7788
Mailing Address - Country:US
Mailing Address - Phone:760-243-7715
Mailing Address - Fax:760-243-5442
Practice Address - Street 1:12830 HESPERIA ROAD, SUITE A
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7788
Practice Address - Country:US
Practice Address - Phone:760-243-7715
Practice Address - Fax:760-243-5442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C500750Medicaid
CAOPT262590Medicare PIN
CA00C500750Medicaid
CAA62195Medicare UPIN