Provider Demographics
NPI:1629027560
Name:SHIELDS ORTHOTIC PROSTHETIC SERVICES, INC.
Entity Type:Organization
Organization Name:SHIELDS ORTHOTIC PROSTHETIC SERVICES, INC.
Other - Org Name:HANGER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-493-8288
Mailing Address - Street 1:2785 E 3300 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2818
Mailing Address - Country:US
Mailing Address - Phone:801-467-5483
Mailing Address - Fax:801-484-4591
Practice Address - Street 1:5687 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4322
Practice Address - Country:US
Practice Address - Phone:801-475-4428
Practice Address - Fax:801-475-0427
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANGER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-09
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY107893300Medicaid
ID002961100Medicaid
WY107893300Medicaid
0189010002Medicare NSC
ID002961100Medicaid