Provider Demographics
NPI:1457521833
Name:GATE CITY ORTHOTICS & PROSTHETICS, INC
Entity Type:Organization
Organization Name:GATE CITY ORTHOTICS & PROSTHETICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-274-2978
Mailing Address - Street 1:1209 MAGNOLIA ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1308
Mailing Address - Country:US
Mailing Address - Phone:336-274-2978
Mailing Address - Fax:336-272-8188
Practice Address - Street 1:1209 MAGNOLIA ST
Practice Address - Street 2:UNIT B
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1308
Practice Address - Country:US
Practice Address - Phone:336-274-2978
Practice Address - Fax:336-272-8188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6175810001Medicare NSC