Provider Demographics
NPI:1881756674
Name:PRECISION ORTHOTIC LABORATORIES, INC.
Entity type:Organization
Organization Name:PRECISION ORTHOTIC LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:CROWDER
Authorized Official - Suffix:SR
Authorized Official - Credentials:CO
Authorized Official - Phone:559-441-7282
Mailing Address - Street 1:1057 R ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1312
Mailing Address - Country:US
Mailing Address - Phone:559-441-7282
Mailing Address - Fax:559-441-7209
Practice Address - Street 1:1057 R ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1312
Practice Address - Country:US
Practice Address - Phone:559-441-7282
Practice Address - Fax:559-441-7209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACO003684332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXA0153181Medicaid
CA3938820001Medicare NSC