Basic Information
Provider Information | |||||||||
NPI: | 1487232211 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTER FOR ORTHOPEDIC RESEARCH AND EDUCATION LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18444 N 25TH AVE STE 310 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850231266 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8669742673 | ||||||||
FaxNumber: | 8669392673 | ||||||||
Practice Location | |||||||||
Address1: | 1485 N TURQUOISE DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | FLAGSTAFF | ||||||||
State: | AZ | ||||||||
PostalCode: | 860012000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282262900 | ||||||||
FaxNumber: | 9282263071 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2021 | ||||||||
LastUpdateDate: | 04/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACOFSKY | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8669742673 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CENTER FOR ORTHOPEDIC RESEARCH AND EDUCATION LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 04/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 335E00000X |   |   | N |   | Suppliers | Prosthetic/Orthotic Supplier |   | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.