Provider Demographics
NPI:1922099159
Name:L.I.C PROSTHETICS AND ORTHOTICS
Entity Type:Organization
Organization Name:L.I.C PROSTHETICS AND ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:FARROKH
Authorized Official - Last Name:RANDJBAR
Authorized Official - Suffix:
Authorized Official - Credentials:BOCPO
Authorized Official - Phone:714-563-0056
Mailing Address - Street 1:321 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3263
Mailing Address - Country:US
Mailing Address - Phone:714-563-0056
Mailing Address - Fax:
Practice Address - Street 1:321 E CENTER ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3263
Practice Address - Country:US
Practice Address - Phone:714-563-0056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC21643335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6512940001Medicare NSC