Provider Demographics
NPI:1588606107
Name:MOLINA ORTHOPEDIC LABORATORIES INC.
Entity Type:Organization
Organization Name:MOLINA ORTHOPEDIC LABORATORIES INC.
Other - Org Name:CROWN CITY ORTHOPEDIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEMOER
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-597-4322
Mailing Address - Street 1:1507 W ALTON AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7219
Mailing Address - Country:US
Mailing Address - Phone:413-233-1105
Mailing Address - Fax:949-209-4424
Practice Address - Street 1:1507 W ALTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7219
Practice Address - Country:US
Practice Address - Phone:413-233-1105
Practice Address - Fax:949-209-4424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2024-03-08
Deactivation Date:2020-03-30
Deactivation Code:
Reactivation Date:2020-05-06
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACO003823OtherAMERICAN BOARD ACCREDITATION (ABC) ORTHOTIST