Provider Demographics
NPI:1861674574
Name:MONTEREY PENNINSULA ORTHOTIC AND PROSTHETIC SERVICES,LLC
Entity Type:Organization
Organization Name:MONTEREY PENNINSULA ORTHOTIC AND PROSTHETIC SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:KIRN
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:831-655-3580
Mailing Address - Street 1:30 RAGSDALE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-7811
Mailing Address - Country:US
Mailing Address - Phone:831-655-3580
Mailing Address - Fax:831-655-3501
Practice Address - Street 1:30 RAGSDALE DR STE 200
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-7811
Practice Address - Country:US
Practice Address - Phone:831-655-3580
Practice Address - Fax:831-655-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ65338ZOtherBLUE SHIELD
CAXC0007762Medicaid
ZZZ65338ZOtherBLUE SHIELD