Provider Demographics
NPI:1811389059
Name:WOODSTONE ORTHOTICS ,PROSTHETICS & MASTECTOMY
Entity Type:Organization
Organization Name:WOODSTONE ORTHOTICS ,PROSTHETICS & MASTECTOMY
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SHANTEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-839-0797
Mailing Address - Street 1:6234 WOODSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2330 SCENIC HWY S
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3115
Practice Address - Country:US
Practice Address - Phone:470-838-0797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier