Provider Demographics
NPI:1740515782
Name:OTTO BOCK ORTHOPEDIC SERVICES LLC
Entity type:Organization
Organization Name:OTTO BOCK ORTHOPEDIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATIONAL PAYOR RELATIONS MGR.
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-806-2879
Mailing Address - Street 1:PO BOX 734949
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4949
Mailing Address - Country:US
Mailing Address - Phone:800-736-8276
Mailing Address - Fax:866-642-2302
Practice Address - Street 1:11809 DOMAIN DR UNIT 110
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-3452
Practice Address - Country:US
Practice Address - Phone:800-736-8276
Practice Address - Fax:866-642-2302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-08
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1001707OtherDEVICE DISTRIBUTOR LICENSE
TX404809201Medicaid
NVMP01413OtherNV STATE BOP-MEDICAL DEVICES, EQUIPMENT, GAS
MDR4009OtherMD DEPT OF HEALTH & MENTAL HYGIENE-RESIDENTIAL SERVICE AGENCY
AZ5453317OtherCCN PIN#
AZ7850253OtherAZ NONHMO PIN #
AZ82108OtherNORTHWOOD NPN PIN#
AZ6337600001Medicare NSC
AZ1220OtherCARECENTRIX PIN #
AZ2624721OtherAETNA HMO PIN #
AZ491709OtherMEDICAID - TUCSON LOCATION