Provider Demographics
NPI:1992019616
Name:DESERT ORTHOTICS LLC
Entity Type:Organization
Organization Name:DESERT ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ERVINE
Authorized Official - Last Name:FATKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-435-7987
Mailing Address - Street 1:600 WHITNEY RANCH DR
Mailing Address - Street 2:SUITE C-13
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2611
Mailing Address - Country:US
Mailing Address - Phone:702-435-7987
Mailing Address - Fax:702-435-7616
Practice Address - Street 1:600 WHITNEY RANCH DR
Practice Address - Street 2:SUITE C13
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-2611
Practice Address - Country:US
Practice Address - Phone:702-435-7987
Practice Address - Fax:702-435-7616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies