Provider Demographics
NPI:1932187218
Name:TUCSON ORTHOPEDIC LAB LLC
Entity type:Organization
Organization Name:TUCSON ORTHOPEDIC LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:520-319-0339
Mailing Address - Street 1:PO BOX 43863
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85733-3863
Mailing Address - Country:US
Mailing Address - Phone:520-319-0339
Mailing Address - Fax:520-319-7825
Practice Address - Street 1:3818 E 5TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-5145
Practice Address - Country:US
Practice Address - Phone:520-319-0339
Practice Address - Fax:520-319-7825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBCBSAZ#0278440OtherBCBS
AZ4282060001Medicare ID - Type Unspecified
AZBCBSAZ#0278440OtherBCBS