Provider Demographics
NPI:1912283953
Name:CREATIVE ORTHOTIC LABS
Entity Type:Organization
Organization Name:CREATIVE ORTHOTIC LABS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HAZELWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-934-3213
Mailing Address - Street 1:8608 N 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-5404
Mailing Address - Country:US
Mailing Address - Phone:623-934-3213
Mailing Address - Fax:623-930-1891
Practice Address - Street 1:8608 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-5404
Practice Address - Country:US
Practice Address - Phone:623-934-3213
Practice Address - Fax:623-930-1891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20519930X335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier