Provider Demographics
NPI:1932365673
Name:HEMET PROSTHETIC & ORTHOTIC GROUP, INC.
Entity Type:Organization
Organization Name:HEMET PROSTHETIC & ORTHOTIC GROUP, INC.
Other - Org Name:HEMET PROSTHETIC & ORTHOTIC GROUP, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:KAUFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:951-766-4297
Mailing Address - Street 1:1133 E FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4512
Mailing Address - Country:US
Mailing Address - Phone:951-766-4297
Mailing Address - Fax:951-766-4299
Practice Address - Street 1:41785 ENTERPRISE CIR S
Practice Address - Street 2:#E
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-9804
Practice Address - Country:US
Practice Address - Phone:951-296-9677
Practice Address - Fax:951-296-9681
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEMET PROSTHETIC & ORTHOTIC GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-01
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXBOO15640Medicaid
CAXBOO15640Medicaid