Provider Demographics
NPI:1851760086
Name:SPECTRUM O & P OF SANTA ROSA
Entity Type:Organization
Organization Name:SPECTRUM O & P OF SANTA ROSA
Other - Org Name:SPECTRUM ORTHOTICS & PROSTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
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 1:3540 E BARNETT STE A
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-734-2435
Mailing Address - Fax:541-734-4366
Practice Address - Street 1:95 MONTGOMERY DR STE 102
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-6617
Practice Address - Country:US
Practice Address - Phone:707-528-8858
Practice Address - Fax:707-528-8840
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHO DEV AMERICA CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-17
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies