Provider Demographics
NPI:1851766752
Name:PROSTHETIC ORTHOTIC SPECIALISTS, INC.
Entity Type:Organization
Organization Name:PROSTHETIC ORTHOTIC SPECIALISTS, INC.
Other - Org Name:CENTER FOR PROSTHETIC & ORTHOTIC DESIGN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-244-0404
Mailing Address - Street 1:PO BOX 91630
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-1630
Mailing Address - Country:US
Mailing Address - Phone:505-244-0404
Mailing Address - Fax:505-244-0708
Practice Address - Street 1:5095 ELLISON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4326
Practice Address - Country:US
Practice Address - Phone:505-244-0404
Practice Address - Fax:505-244-0708
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELITE PROSTHETICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-04
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0000T6178Medicaid
NM0334560001Medicare NSC