Provider Demographics
NPI:1356370423
Name:ODYSSEY PROSTHETICS & ORTHOTICS INC.
Entity type:Organization
Organization Name:ODYSSEY PROSTHETICS & ORTHOTICS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:OPENSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:909-890-0577
Mailing Address - Street 1:738 S WATERMAN AVE STE A4
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2355
Mailing Address - Country:US
Mailing Address - Phone:909-890-0577
Mailing Address - Fax:909-890-5504
Practice Address - Street 1:738 S WATERMAN AVE STE A4
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2355
Practice Address - Country:US
Practice Address - Phone:909-890-0577
Practice Address - Fax:909-890-5504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO1431335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXB0021550Medicaid
CA=========OtherEMPLOYEE ID NUMBER
CA=========OtherEMPLOYEE ID NUMBER