Provider Demographics
NPI:1851669584
Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - NORTHWEST, LLC
Entity Type:Organization
Organization Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - NORTHWEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:503-221-3430
Mailing Address - Street 1:3101 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3009
Mailing Address - Country:US
Mailing Address - Phone:503-221-3430
Mailing Address - Fax:
Practice Address - Street 1:3101 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3009
Practice Address - Country:US
Practice Address - Phone:503-221-3430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - NORTHWEST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-08
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier