Provider Demographics
NPI:1770876195
Name:DYNAMIC ORTHOTIC SERVICES, INC.
Entity type:Organization
Organization Name:DYNAMIC ORTHOTIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MARGAGLIO
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:337-291-1016
Mailing Address - Street 1:103 E PINHOOK RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-8531
Mailing Address - Country:US
Mailing Address - Phone:337-291-1016
Mailing Address - Fax:337-704-0324
Practice Address - Street 1:1327 ENTERPRISE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-6323
Practice Address - Country:US
Practice Address - Phone:337-291-1016
Practice Address - Fax:337-704-0324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1187143Medicaid
LA1266440004Medicare PIN