Provider Demographics
NPI:1700828944
Name:BLUEBIRD ORTHOTICS AND PROSTHETICS, INC.
Entity Type:Organization
Organization Name:BLUEBIRD ORTHOTICS AND PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-874-6750
Mailing Address - Street 1:4373 VIEWRIDGE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-874-6750
Mailing Address - Fax:858-874-6736
Practice Address - Street 1:4373 VIEWRIDGE AVE
Practice Address - Street 2:STE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1619
Practice Address - Country:US
Practice Address - Phone:858-874-6750
Practice Address - Fax:858-874-6736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97948241335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXA000080Medicaid
CAGXA000080Medicaid