Provider Demographics
NPI:1265440234
Name:PERFORMANCE PROSTHETIC ORTHOTIC CENTER
Entity type:Organization
Organization Name:PERFORMANCE PROSTHETIC ORTHOTIC CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:FLOYD
Authorized Official - Last Name:RAPPOPORT
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:310-829-2322
Mailing Address - Street 1:PO BOX 3256
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90408-3256
Mailing Address - Country:US
Mailing Address - Phone:310-829-2322
Mailing Address - Fax:310-315-3634
Practice Address - Street 1:2820 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2410
Practice Address - Country:US
Practice Address - Phone:310-829-2322
Practice Address - Fax:310-315-3634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43027332B00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000450Medicaid
=========OtherFOR BILLING INSURANCE COM
=========OtherFOR BILLING INSURANCE COM