Provider Demographics
NPI:1477077113
Name:PROSTRIDE ORTHOTICS LLC
Entity Type:Organization
Organization Name:PROSTRIDE ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BHARTI
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-310-3894
Mailing Address - Street 1:PO BOX 5382
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23058-5382
Mailing Address - Country:US
Mailing Address - Phone:804-310-3894
Mailing Address - Fax:
Practice Address - Street 1:9609 GAYTON RD STE 102
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23238-4900
Practice Address - Country:US
Practice Address - Phone:804-310-3894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA4134224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthistGroup - Single Specialty