Provider Demographics
NPI:1497893788
Name:PROSTHETIC & ORTHOTIC GROUP, INC
Entity Type:Organization
Organization Name:PROSTHETIC & ORTHOTIC GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MATSUSHIMA
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:562-595-6445
Mailing Address - Street 1:2669 MYRTLE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-2746
Mailing Address - Country:US
Mailing Address - Phone:562-945-4920
Mailing Address - Fax:562-945-9360
Practice Address - Street 1:12200 WASHINGTON BLVD STE M
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90606-2579
Practice Address - Country:US
Practice Address - Phone:562-945-4920
Practice Address - Fax:562-945-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4203460002Medicare NSC