Provider Demographics
NPI:1629722889
Name:EPIC PROSTHETICS AND ORTHOTICS LLC
Entity Type:Organization
Organization Name:EPIC PROSTHETICS AND ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:COBURN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPO, MSPO
Authorized Official - Phone:801-820-0045
Mailing Address - Street 1:635 N MAIN ST STE 691
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-1895
Mailing Address - Country:US
Mailing Address - Phone:801-820-0087
Mailing Address - Fax:801-820-2852
Practice Address - Street 1:635 N MAIN ST STE 691
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-1895
Practice Address - Country:US
Practice Address - Phone:801-820-0087
Practice Address - Fax:801-820-2852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-07
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Single Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty