Provider Demographics
NPI:1295916344
Name:PREMIER ORTHOTICS & PROSTHETICS, INC
Entity type:Organization
Organization Name:PREMIER ORTHOTICS & PROSTHETICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:404-292-4200
Mailing Address - Street 1:753 N INDIAN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-2347
Mailing Address - Country:US
Mailing Address - Phone:404-292-4200
Mailing Address - Fax:404-292-4247
Practice Address - Street 1:753 N INDIAN CREEK DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-2347
Practice Address - Country:US
Practice Address - Phone:404-292-4200
Practice Address - Fax:404-292-4247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0078335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00846513AMedicaid
GA00846513AMedicaid