Provider Demographics
NPI:1538106406
Name:PROSTHETIC ORTHOTIC & PEDORTHIC ASSOCIATES, INC
Entity Type:Organization
Organization Name:PROSTHETIC ORTHOTIC & PEDORTHIC ASSOCIATES, INC
Other - Org Name:POPA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:870-932-6436
Mailing Address - Street 1:PO BOX 9303
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-9303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 GERMAN OAK DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7220
Practice Address - Country:US
Practice Address - Phone:901-751-0069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03581011Medicaid
TN1455109Medicaid
TN1455109Medicaid