Provider Demographics
NPI:1821484056
Name:SPECTRUM OF SANTA ROSA
Entity Type:Organization
Organization Name:SPECTRUM OF SANTA ROSA
Other - Org Name:SPECTRUM ORTHOTICS & PROSTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHOTIST/PROSTHETIST
Authorized Official - Prefix:MR
Authorized Official - First Name:FOREST
Authorized Official - Middle Name:R
Authorized Official - Last Name:SEXTON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:541-734-2435
Mailing Address - Street 1:1180 CRATER LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6242
Mailing Address - Country:US
Mailing Address - Phone:541-734-2435
Mailing Address - Fax:541-734-4366
Practice Address - Street 1:1041 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4329
Practice Address - Country:US
Practice Address - Phone:541-734-2435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier