Provider Demographics
NPI:1265554984
Name:SPECTRUM PROSTHETICS AND ORTHOTICS, LLC
Entity type:Organization
Organization Name:SPECTRUM PROSTHETICS AND ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FOREST
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:SEXTON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:541-734-2435
Mailing Address - Street 1:300 UNION AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5861
Mailing Address - Country:US
Mailing Address - Phone:541-955-9678
Mailing Address - Fax:541-471-4909
Practice Address - Street 1:300 UNION AVE STE C
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5861
Practice Address - Country:US
Practice Address - Phone:541-955-9678
Practice Address - Fax:541-471-4909
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHO DEV AMERICA CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-04
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X, 332B00000X
NA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500637334Medicaid