Provider Demographics
NPI:1497856710
Name:WILLIAMSBURG ORTHOTICS AND PROSTHETICS INC
Entity Type:Organization
Organization Name:WILLIAMSBURG ORTHOTICS AND PROSTHETICS INC
Other - Org Name:CERTIFIED PROSTHETIC & ORTHOTIC SPECIALIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPO CPED
Authorized Official - Phone:757-833-0911
Mailing Address - Street 1:802 LOCKWOOD AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4479
Mailing Address - Country:US
Mailing Address - Phone:757-833-0911
Mailing Address - Fax:757-833-1099
Practice Address - Street 1:802 LOCKWOOD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4479
Practice Address - Country:US
Practice Address - Phone:757-833-0911
Practice Address - Fax:757-833-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA100478335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
116688OtherVERISYSTEMS
VA261848OtherBC/BS
VA0009190392Medicaid
VA0009190392Medicaid