Provider Demographics
NPI:1477822336
Name:DICKSON ORTHOTICS & PROSTHETICS
Entity Type:Organization
Organization Name:DICKSON ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CPO
Authorized Official - Prefix:MR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:LARA
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:615-740-0177
Mailing Address - Street 1:127 CRESTVIEW PARK DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-2855
Mailing Address - Country:US
Mailing Address - Phone:615-740-0177
Mailing Address - Fax:615-740-1154
Practice Address - Street 1:127 CRESTVIEW PARK DR
Practice Address - Street 2:SUITE 104
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2855
Practice Address - Country:US
Practice Address - Phone:615-740-0177
Practice Address - Fax:615-740-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECPO02324332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4319966OtherBLUE CROSS BLUE SHIELD
TN4319966OtherBLUE CROSS BLUE SHIELD