Provider Demographics
NPI:1922104751
Name:FONTANA ARTIFICIAL LIMB & BRACE INC.
Entity Type:Organization
Organization Name:FONTANA ARTIFICIAL LIMB & BRACE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CERTIFIED PROSTHETIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-822-3233
Mailing Address - Street 1:8576 NUEVO AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3826
Mailing Address - Country:US
Mailing Address - Phone:909-822-3233
Mailing Address - Fax:909-822-6480
Practice Address - Street 1:8576 NUEVO AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3826
Practice Address - Country:US
Practice Address - Phone:909-822-3233
Practice Address - Fax:909-822-6480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000370Medicaid
CAGXC000370Medicaid