Provider Demographics
NPI:1477805315
Name:MAUGHAN PROSTHETIC & ORTHOTIC SOUTH, INC.
Entity Type:Organization
Organization Name:MAUGHAN PROSTHETIC & ORTHOTIC SOUTH, INC.
Other - Org Name:MAUGHAN PROSTHETIC & ORTHOTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPO
Authorized Official - Phone:253-820-3689
Mailing Address - Street 1:PO BOX 1546
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-1546
Mailing Address - Country:US
Mailing Address - Phone:360-447-0770
Mailing Address - Fax:253-875-7768
Practice Address - Street 1:208 LILLY RD NE
Practice Address - Street 2:SUITE A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-6100
Practice Address - Country:US
Practice Address - Phone:360-338-0284
Practice Address - Fax:360-878-8492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-02
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS00000183335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6712990001Medicare NSC