Provider Demographics
NPI:1407855760
Name:THE ORTHOPEDIC STORE
Entity type:Organization
Organization Name:THE ORTHOPEDIC STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:HARIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-366-2990
Mailing Address - Street 1:PO BOX 792590
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78279-2590
Mailing Address - Country:US
Mailing Address - Phone:512-302-9370
Mailing Address - Fax:512-302-9370
Practice Address - Street 1:8311 BURNET RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-7714
Practice Address - Country:US
Practice Address - Phone:512-302-9370
Practice Address - Fax:512-302-9374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0046447332B00000X
TX101021335E00000X
TX261QP2000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Not Answered261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Not Answered261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00147SMedicare ID - Type UnspecifiedPHYSICAL THERAPY NUMBER
TX1283180003Medicare NSC