Provider Demographics
NPI:1639367311
Name:WILLAMETTE ORTHOTICS & PROSTHETICS LLC
Entity Type:Organization
Organization Name:WILLAMETTE ORTHOTICS & PROSTHETICS LLC
Other - Org Name:SUMMIT ORTHOTICS & PROSTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:J
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:503-364-6006
Mailing Address - Street 1:PO BOX 7339
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303-0102
Mailing Address - Country:US
Mailing Address - Phone:503-364-6006
Mailing Address - Fax:503-364-6046
Practice Address - Street 1:400 NW WALNUT BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3874
Practice Address - Country:US
Practice Address - Phone:541-738-2462
Practice Address - Fax:541-738-0664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
3976240008Medicare NSC
3976240008Medicare PIN
3976240008Medicare NSC