Provider Demographics
NPI:1639789779
Name:DYNAMICS ORTHOTICS & PROSTHETICS, INC
Entity Type:Organization
Organization Name:DYNAMICS ORTHOTICS & PROSTHETICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-383-9212
Mailing Address - Street 1:1830 W OLYMPIC BLVD STE 123
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-3734
Mailing Address - Country:US
Mailing Address - Phone:213-383-9212
Mailing Address - Fax:
Practice Address - Street 1:2150 N WATERMAN AVE STE 301
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4811
Practice Address - Country:US
Practice Address - Phone:909-881-3612
Practice Address - Fax:909-881-3613
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DYNAMICS ORTHOTICS & PROSTHETICS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy FitterGroup - Multi-Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000070Medicaid
CACP003476OtherABCOP,