Provider Demographics
NPI:1982202545
Name:DAVIDSON PROSTHETICS & ORTHOTICS
Entity Type:Organization
Organization Name:DAVIDSON PROSTHETICS & ORTHOTICS
Other - Org Name:RENEW PROSTHETICS AND ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER CONTRACT ANALYST III
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGELINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-961-2102
Mailing Address - Street 1:PO BOX 650846
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:845 CHURCH ST N STE 205
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4374
Practice Address - Country:US
Practice Address - Phone:704-467-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANGER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-15
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment