Provider Demographics
NPI:1285640979
Name:PRECISION ORTHOTICS & PROSTHETICS INC
Entity type:Organization
Organization Name:PRECISION ORTHOTICS & PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KWON
Authorized Official - Middle Name:CHAE
Authorized Official - Last Name:YI
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED PROSTHETIS
Authorized Official - Phone:213-388-5847
Mailing Address - Street 1:7143 SEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4905
Mailing Address - Country:US
Mailing Address - Phone:213-388-5847
Mailing Address - Fax:213-388-5848
Practice Address - Street 1:7143 SEVILLE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4905
Practice Address - Country:US
Practice Address - Phone:213-388-5847
Practice Address - Fax:213-388-5848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ655562OtherBLUE SHIELD OF CALIFORNIA
CAXB0023570Medicaid
CAXB0023570Medicaid
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