Provider Demographics
NPI:1972656270
Name:PROWALK ORTHOTICS & PROSTHETICS, INC.
Entity Type:Organization
Organization Name:PROWALK ORTHOTICS & PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANG
Authorized Official - Middle Name:C
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:818-782-3435
Mailing Address - Street 1:7232 VAN NUYS BLVD
Mailing Address - Street 2:#205
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2231
Mailing Address - Country:US
Mailing Address - Phone:818-782-3435
Mailing Address - Fax:818-782-6858
Practice Address - Street 1:7232 VAN NUYS BLVD
Practice Address - Street 2:#205
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2231
Practice Address - Country:US
Practice Address - Phone:818-782-3435
Practice Address - Fax:818-782-6858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0019745Medicaid
4551560001Medicare ID - Type Unspecified