Provider Demographics
NPI:1154371375
Name:PARK PROSTHETICS AND ORTHOTICS, INC.
Entity type:Organization
Organization Name:PARK PROSTHETICS AND ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:CP, LP
Authorized Official - Phone:361-888-5347
Mailing Address - Street 1:2222 MORGAN AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78405-1948
Mailing Address - Country:US
Mailing Address - Phone:361-888-5347
Mailing Address - Fax:361-888-5345
Practice Address - Street 1:2222 MORGAN AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-1948
Practice Address - Country:US
Practice Address - Phone:361-888-5347
Practice Address - Fax:361-888-5345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101103335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0039519OtherMEDICAL DEVICE MANUFACTUR
TX101103OtherTEXAS BOARD OF O&P LIC.
TX101103OtherTEXAS BOARD OF O&P LIC.