Provider Demographics
NPI:1558398750
Name:ADVANCE ORTHOTIC & PROSTHETIC SERVICES, INC.
Entity Type:Organization
Organization Name:ADVANCE ORTHOTIC & PROSTHETIC SERVICES, INC.
Other - Org Name:ADVANCE ORTHOTIC SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:207-786-7022
Mailing Address - Street 1:207 NORTH RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210
Mailing Address - Country:US
Mailing Address - Phone:207-786-7022
Mailing Address - Fax:207-777-1787
Practice Address - Street 1:207 NORTH RIVER ROAD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210
Practice Address - Country:US
Practice Address - Phone:207-786-7022
Practice Address - Fax:207-777-1787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
132230001OtherMAINECARE
ME132230000Medicaid
ME132230000Medicaid
132230001OtherMAINECARE