Provider Demographics
NPI:1689713265
Name:PREFERRED ORTHOTIC AND PROSTHETIC SERVICES INC
Entity Type:Organization
Organization Name:PREFERRED ORTHOTIC AND PROSTHETIC SERVICES INC
Other - Org Name:EVERGREEN PROSTHETICS AND ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:503-407-5408
Mailing Address - Street 1:8880 SW NIMBUS AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7111
Mailing Address - Country:US
Mailing Address - Phone:877-971-7272
Mailing Address - Fax:971-727-3162
Practice Address - Street 1:922 S 348TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-7021
Practice Address - Country:US
Practice Address - Phone:253-952-3887
Practice Address - Fax:253-927-3058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1689713265Medicaid