Provider Demographics
NPI:1649204801
Name:TEMECULA VALLEY ORTHOITCS & PROSTHETICS, INC.
Entity Type:Organization
Organization Name:TEMECULA VALLEY ORTHOITCS & PROSTHETICS, INC.
Other - Org Name:TEMECULA VALLEY O&P
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATHENY
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:951-696-4447
Mailing Address - Street 1:36243 INLAND VALLEY DR STE 30
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-9547
Mailing Address - Country:US
Mailing Address - Phone:951-696-4447
Mailing Address - Fax:951-696-4448
Practice Address - Street 1:36243 INLAND VALLEY DR STE 30
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-9547
Practice Address - Country:US
Practice Address - Phone:951-696-4447
Practice Address - Fax:951-696-4448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CPO19140335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03626ZOtherBLUE SHIELD PROVIDER NUMB
CA4898339OtherBLUE CROSS PROVIDER NUMBE
CA5573OtherHEALTH NET PROVIDER NUMBE
CAXC0019140Medicaid
CACMS170123Medicaid
CAXC0019140Medicaid