Provider Demographics
NPI:1316700743
Name:PROSTHETIC & ORTHOTIC GROUP BOULDER LLC
Entity type:Organization
Organization Name:PROSTHETIC & ORTHOTIC GROUP BOULDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATSUSHIMA
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:562-595-6445
Mailing Address - Street 1:2850 IRIS AVE STE I4
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1493
Mailing Address - Country:US
Mailing Address - Phone:303-381-4500
Mailing Address - Fax:970-416-9359
Practice Address - Street 1:2850 IRIS AVE STE I4
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1493
Practice Address - Country:US
Practice Address - Phone:303-381-4500
Practice Address - Fax:970-416-9359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier