Provider Demographics
NPI:1811305055
Name:PERFORMANCE ORTHOTICS & PROSTHETICS, INC.
Entity type:Organization
Organization Name:PERFORMANCE ORTHOTICS & PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:719-425-6007
Mailing Address - Street 1:729 FORTINO BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2089
Mailing Address - Country:US
Mailing Address - Phone:719-425-6007
Mailing Address - Fax:
Practice Address - Street 1:729 FORTINO BLVD STE A
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2089
Practice Address - Country:US
Practice Address - Phone:719-425-6007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
CO335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment