Provider Demographics
NPI:1205353463
Name:PROSTHETIC & ORTHOTIC GROUP, INC
Entity type:Organization
Organization Name:PROSTHETIC & ORTHOTIC GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MATSUSHIMA
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:424-299-4757
Mailing Address - Street 1:2669 MYRTLE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-2746
Mailing Address - Country:US
Mailing Address - Phone:562-595-6445
Mailing Address - Fax:562-424-3122
Practice Address - Street 1:3510 TORRANCE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4824
Practice Address - Country:US
Practice Address - Phone:424-299-4757
Practice Address - Fax:562-424-3122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier