Provider Demographics
NPI:1356430482
Name:ORTHO SHOCK WAVE THERAPY, INC.
Entity type:Organization
Organization Name:ORTHO SHOCK WAVE THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-966-9335
Mailing Address - Street 1:3303 HARBOR BLVD
Mailing Address - Street 2:SUITE H2
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-1530
Mailing Address - Country:US
Mailing Address - Phone:714-966-9335
Mailing Address - Fax:714-966-9706
Practice Address - Street 1:3636 HARBOR BLVD
Practice Address - Street 2:H2
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626
Practice Address - Country:US
Practice Address - Phone:714-966-9335
Practice Address - Fax:714-966-9706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty