Provider Demographics
NPI:1639482367
Name:DYNAMIC ORTHO SUPPLY
Entity Type:Organization
Organization Name:DYNAMIC ORTHO SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SOSI
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIDOSTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-480-1879
Mailing Address - Street 1:PO BOX 3996
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91508-3996
Mailing Address - Country:US
Mailing Address - Phone:818-480-1879
Mailing Address - Fax:818-845-5925
Practice Address - Street 1:943 CAMBRIDGE DR
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504-1916
Practice Address - Country:US
Practice Address - Phone:818-480-1879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101-595313332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies