Provider Demographics
NPI:1548576366
Name:DIABLO PROSTHETICS & ORTHOTICS INC.
Entity Type:Organization
Organization Name:DIABLO PROSTHETICS & ORTHOTICS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPO, MBA
Authorized Official - Phone:209-612-6168
Mailing Address - Street 1:120 LA CASA VIA
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3067
Mailing Address - Country:US
Mailing Address - Phone:925-930-7700
Mailing Address - Fax:925-930-7609
Practice Address - Street 1:120 LA CASA VIA
Practice Address - Street 2:SUITE 202
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3067
Practice Address - Country:US
Practice Address - Phone:925-930-7700
Practice Address - Fax:925-930-7609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-31
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1548576366Medicaid
5856740002Medicare PIN