Provider Demographics
NPI:1518105840
Name:STELLAR PROSTHETICS & ORTHOTICS
Entity Type:Organization
Organization Name:STELLAR PROSTHETICS & ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STELLAR
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:626-584-0805
Mailing Address - Street 1:753 S ARROYO PKWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3902
Mailing Address - Country:US
Mailing Address - Phone:626-584-0805
Mailing Address - Fax:626-584-0806
Practice Address - Street 1:3831 CATALINA ST
Practice Address - Street 2:SUITE B
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-5405
Practice Address - Country:US
Practice Address - Phone:626-584-0805
Practice Address - Fax:626-584-0806
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STELLAR PROSTHETICS & ORTHOTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97942973335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0001829Medicaid
CAXC0001829Medicaid