Provider Demographics
NPI:1437468501
Name:DREW HITTENBERGER
Entity Type:Organization
Organization Name:DREW HITTENBERGER
Other - Org Name:HITTENBERGER ORTHOTICS AND PROSTHETICS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:ARNOLD
Authorized Official - Last Name:HITTENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:CP BOCO
Authorized Official - Phone:707-765-1122
Mailing Address - Street 1:181 LYNCH CREEK WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-2372
Mailing Address - Country:US
Mailing Address - Phone:707-765-1122
Mailing Address - Fax:707-765-4571
Practice Address - Street 1:181 LYNCH CREEK WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2372
Practice Address - Country:US
Practice Address - Phone:707-765-1122
Practice Address - Fax:707-765-4571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-06
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACP1093335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA412983007OtherPTAN KENTIFIELD
CAGXC000123Medicaid
CA412983006OtherPTAN SANTA ROSA
CAGXC000123Medicaid