Provider Demographics
NPI:1487639647
Name:INNOVATIVE PROSTHETIC SOLUTIONS, INC
Entity Type:Organization
Organization Name:INNOVATIVE PROSTHETIC SOLUTIONS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:TYRA
Authorized Official - Last Name:RIKIMARU
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:949-699-0600
Mailing Address - Street 1:2 S POINTE DR STE 240
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2281
Mailing Address - Country:US
Mailing Address - Phone:949-699-0600
Mailing Address - Fax:
Practice Address - Street 1:2 S POINTE DR STE 240
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2281
Practice Address - Country:US
Practice Address - Phone:949-699-0600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0010901Medicaid
CAZZZ65372ZOtherBLUE SHIELD OF CA
CAXC0010901Medicaid