Provider Demographics
NPI:1992743090
Name:DOUGLASS CERT PROS & ORTHOTICS, INC
Entity type:Organization
Organization Name:DOUGLASS CERT PROS & 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:STEPHEN
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:510-537-1210
Mailing Address - Street 1:15225 AURORA AVE N
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-6123
Mailing Address - Country:US
Mailing Address - Phone:206-363-7790
Mailing Address - Fax:206-363-7688
Practice Address - Street 1:15225 AURORA AVE N
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-6123
Practice Address - Country:US
Practice Address - Phone:206-363-7790
Practice Address - Fax:206-363-7688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS00000063335E00000X
WAOI00000062335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9041328Medicaid
WA9041328Medicaid