Provider Demographics
NPI:1629084942
Name:CAPSTONE ORTHOPEDIC, INC.
Entity Type:Organization
Organization Name:CAPSTONE ORTHOPEDIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:209-612-6168
Mailing Address - Street 1:19845 LAKE CHABOT RD STE 302
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-4055
Mailing Address - Country:US
Mailing Address - Phone:510-537-1210
Mailing Address - Fax:510-537-1082
Practice Address - Street 1:19845 LAKE CHABOT RD STE 302
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4055
Practice Address - Country:US
Practice Address - Phone:510-537-1210
Practice Address - Fax:510-537-1082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC 000920Medicaid
5772670001Medicare NSC