Provider Demographics
NPI:1780900852
Name:PETTIES & ASSOCIATES ORTHOTIC / PROSTHETICS, LLC
Entity type:Organization
Organization Name:PETTIES & ASSOCIATES ORTHOTIC / PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:V
Authorized Official - Last Name:PETTIES
Authorized Official - Suffix:SR
Authorized Official - Credentials:CPO/FAAOP
Authorized Official - Phone:901-270-5470
Mailing Address - Street 1:1089 EASTMORELAND AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3334
Mailing Address - Country:US
Mailing Address - Phone:901-275-8358
Mailing Address - Fax:901-525-9378
Practice Address - Street 1:1089 EASTMORELAND AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3334
Practice Address - Country:US
Practice Address - Phone:901-275-8358
Practice Address - Fax:901-525-9378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-14
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN188 / 230335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier