Provider Demographics
NPI:1487148847
Name:MAUGHAN PROSTHETIC & ORTHOTIC, INC.
Entity type:Organization
Organization Name:MAUGHAN PROSTHETIC & ORTHOTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMIN/CFO
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:EADS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-447-0770
Mailing Address - Street 1:PO BOX 1546
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-1546
Mailing Address - Country:US
Mailing Address - Phone:360-447-0770
Mailing Address - Fax:253-904-8705
Practice Address - Street 1:127 SW 156TH ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166
Practice Address - Country:US
Practice Address - Phone:206-246-2714
Practice Address - Fax:206-246-4665
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAUGHAN PROSTHETIC & ORTHOTIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-19
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI00000067222Z00000X
WAPS00000068224P00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2007326Medicaid