Provider Demographics
NPI:1316124324
Name:MILLEDGEVILLE ORTHOTICS INC
Entity type:Organization
Organization Name:MILLEDGEVILLE ORTHOTICS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CLAUDE
Authorized Official - Last Name:EASON
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED ORTHOTIST
Authorized Official - Phone:478-453-7327
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:HARDWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31034-0564
Mailing Address - Country:US
Mailing Address - Phone:478-453-7327
Mailing Address - Fax:478-451-0741
Practice Address - Street 1:535 N COBB ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2636
Practice Address - Country:US
Practice Address - Phone:478-453-7327
Practice Address - Fax:478-451-0741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000018335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000018OtherGA LIC. ORTHOTIST
GA0321370001Medicare NSC