Provider Demographics
NPI:1750588505
Name:PRINCE WILLIAM ORTHOTICS & PROSTHETICS LLC
Entity type:Organization
Organization Name:PRINCE WILLIAM ORTHOTICS & PROSTHETICS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:GARNEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:703-386-7967
Mailing Address - Street 1:10322 BATTLEVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2338
Mailing Address - Country:US
Mailing Address - Phone:703-368-7967
Mailing Address - Fax:703-368-7867
Practice Address - Street 1:10322 BATTLEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2338
Practice Address - Country:US
Practice Address - Phone:703-368-7967
Practice Address - Fax:703-368-7867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA015167912Medicaid
VA305536OtherANTHEM BC/BS
VA331805OtherAMERIGROUP
VA9703085OtherAETNA
MD014937300Medicaid
VA=========OtherTRICARE NORTH REGION
VA015167912Medicaid