Provider Demographics
NPI:1538295654
Name:VALLEY ORTHOTIC INC.
Entity Type:Organization
Organization Name:VALLEY ORTHOTIC INC.
Other - Org Name:VALLEY ORTHOPEDIC, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCO CERTIFIED ORT
Authorized Official - Phone:509-922-5040
Mailing Address - Street 1:11412 E. SPRAGUE AVE.
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-5224
Mailing Address - Country:US
Mailing Address - Phone:509-922-5040
Mailing Address - Fax:509-922-5041
Practice Address - Street 1:11412 E. SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-5224
Practice Address - Country:US
Practice Address - Phone:509-922-5040
Practice Address - Fax:509-922-5041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-25
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600550953332BC3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9562901Medicaid
0330440001Medicare UPIN
WA9562901Medicaid