Provider Demographics
NPI:1821048034
Name:ISLAND PROSTHETICS & ORTHOTICS, INC.
Entity Type:Organization
Organization Name:ISLAND PROSTHETICS & ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:LCP
Authorized Official - Phone:360-678-4700
Mailing Address - Street 1:6921 HIGH POINT DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WA
Mailing Address - Zip Code:98236-8702
Mailing Address - Country:US
Mailing Address - Phone:360-678-4700
Mailing Address - Fax:360-678-4711
Practice Address - Street 1:80 N. MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239
Practice Address - Country:US
Practice Address - Phone:360-678-4700
Practice Address - Fax:360-678-4711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602433234335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0143888OtherLABOR & INDUSTRIES, WA
WA5780ISOtherREGENCE BLUE SHIELD
WA9052986Medicaid
WA5394040001Medicare NSC