Provider Demographics
NPI:1912289216
Name:TIERNEY, CYNTHIA VESTAL (BOCO)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:VESTAL
Last Name:TIERNEY
Suffix:
Gender:F
Credentials:BOCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 WESTGATE CENTER DR. STE B
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-546-7165
Mailing Address - Fax:866-403-2483
Practice Address - Street 1:TIERNEY ORTHOTICS AND PROSTHETICS INC
Practice Address - Street 2:1345 WESTGATE CENTER DR, STE B
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-546-7165
Practice Address - Fax:866-403-2483
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795524Medicaid
NC7212750001Medicare NSC