Provider Demographics
NPI:1558545418
Name:DYNAMIC PROSTHETIC & ORTHOTIC
Entity Type:Organization
Organization Name:DYNAMIC PROSTHETIC & ORTHOTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:ROOKS
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-622-2000
Mailing Address - Street 1:2700 WESTSIDE DR NW
Mailing Address - Street 2:SUITE 306
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3699
Mailing Address - Country:US
Mailing Address - Phone:423-478-5093
Mailing Address - Fax:423-622-2400
Practice Address - Street 1:2700 WESTSIDE DR NW
Practice Address - Street 2:SUITE 306
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-3699
Practice Address - Country:US
Practice Address - Phone:423-478-5093
Practice Address - Fax:423-622-2400
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DYNAMIC PROSTHETIC & ORTHOTIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4033710OtherBLUECARE
TN1454227Medicaid
TN1454227Medicaid