Provider Demographics
NPI:1912991738
Name:NORTHWEST ORTHOTICS & PROSTHETICS INC
Entity type:Organization
Organization Name:NORTHWEST ORTHOTICS & PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER CONTRACT ANALYST III
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGELINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-961-2102
Mailing Address - Street 1:PO BOX 650846
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1675 N FREEDOM BLVD STE 12C
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6940
Practice Address - Country:US
Practice Address - Phone:801-377-3433
Practice Address - Fax:801-377-4127
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANGER CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-08
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 335E00000X
UTD44206332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT820305315003Medicaid
UT820305315003Medicaid