Provider Demographics
NPI:1578992319
Name:IMAGE PROSTHETICS INCORPORATED
Entity Type:Organization
Organization Name:IMAGE PROSTHETICS INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:KLUGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:BCO
Authorized Official - Phone:909-478-9081
Mailing Address - Street 1:11306 MOUNTAIN VIEW AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3832
Mailing Address - Country:US
Mailing Address - Phone:909-478-9081
Mailing Address - Fax:909-478-9084
Practice Address - Street 1:11306 MOUNTAIN VIEW AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3832
Practice Address - Country:US
Practice Address - Phone:909-478-9081
Practice Address - Fax:909-478-9084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7363230001Medicare NSC