Provider Demographics
NPI:1609170737
Name:PRECISION ORTHOTICS & PROSTHETICS, LLC
Entity Type:Organization
Organization Name:PRECISION ORTHOTICS & PROSTHETICS, LLC
Other - Org Name:POP PROSTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-864-8783
Mailing Address - Street 1:526 S TONOPAH DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4043
Mailing Address - Country:US
Mailing Address - Phone:702-293-5502
Mailing Address - Fax:702-259-7671
Practice Address - Street 1:526 S TONOPAH DR
Practice Address - Street 2:SUITE 120
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4043
Practice Address - Country:US
Practice Address - Phone:702-243-7671
Practice Address - Fax:702-259-7671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100517503Medicaid
NV100509314Medicaid