Provider Demographics
NPI:1558559484
Name:TAMMY L DIRKSEN
Entity Type:Organization
Organization Name:TAMMY L DIRKSEN
Other - Org Name:CENTRAL ORTHOTIC & PROSTHETIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIRKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:559-251-5557
Mailing Address - Street 1:2039 N FINE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1512
Mailing Address - Country:US
Mailing Address - Phone:559-251-5557
Mailing Address - Fax:559-251-5559
Practice Address - Street 1:2039 N FINE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-1512
Practice Address - Country:US
Practice Address - Phone:559-251-5557
Practice Address - Fax:559-251-5559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000650Medicaid
CA1039420001Medicare NSC