Provider Demographics
NPI:1386930873
Name:DIABLO PROSTHETICS & ORTHOTICS, INC
Entity type:Organization
Organization Name:DIABLO PROSTHETICS & ORTHOTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPO, MBA
Authorized Official - Phone:209-612-6168
Mailing Address - Street 1:PO BOX 5268
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-0468
Mailing Address - Country:US
Mailing Address - Phone:925-484-6400
Mailing Address - Fax:925-484-6497
Practice Address - Street 1:2157 COUNTRY HILLS DR STE 208
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-7401
Practice Address - Country:US
Practice Address - Phone:925-755-9507
Practice Address - Fax:925-755-9454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1386930873Medicaid
CA1386930873Medicaid