Provider Demographics
NPI:1669655999
Name:DYNAMIC PROSTHETIC & ORTHOTIC, LLC
Entity Type:Organization
Organization Name:DYNAMIC PROSTHETIC & ORTHOTIC, LLC
Other - Org Name:PROSTHETIC AND ORTHOTIC ASSOCIATES OF TENNESSEE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-622-2000
Mailing Address - Street 1:2116 MCCALLIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-3118
Mailing Address - Country:US
Mailing Address - Phone:423-622-2000
Mailing Address - Fax:423-622-2400
Practice Address - Street 1:2116 MCCALLIE AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3118
Practice Address - Country:US
Practice Address - Phone:423-622-2000
Practice Address - Fax:423-622-2400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4033710OtherBLUECARE/BLUECROSS
GA000951684AMedicaid
TN1454227Medicaid
TN4033710OtherBLUECARE/BLUECROSS