Provider Demographics
NPI:1912606583
Name:DOUGLASS CERT PROS & ORTHOTICS, INC
Entity Type:Organization
Organization Name:DOUGLASS CERT PROS & ORTHOTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-537-1210
Mailing Address - Street 1:4509 TALBOT RD S STE 103
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6294
Mailing Address - Country:US
Mailing Address - Phone:425-547-4070
Mailing Address - Fax:425-547-4071
Practice Address - Street 1:4509 TALBOT RD S STE 103
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6294
Practice Address - Country:US
Practice Address - Phone:425-547-4070
Practice Address - Fax:425-547-4071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier