Basic Information
Provider Information | |||||||||
NPI: | 1932506821 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORTHOTIC PROSTHETIC CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8330 PROFESSIONAL HILL DR | ||||||||
Address2: |   | ||||||||
City: | FAIRFAX | ||||||||
State: | VA | ||||||||
PostalCode: | 220314611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7036985007 | ||||||||
FaxNumber: | 7032079395 | ||||||||
Practice Location | |||||||||
Address1: | 224 CORNWALL ST NW | ||||||||
Address2: | CORNWALL PAVILION BUILDING 224-D SUITE 200B | ||||||||
City: | LEESBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 201762701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5712913121 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2014 | ||||||||
LastUpdateDate: | 02/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CORCORAN | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3019060603 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPO | ||||||||
NPICertificationDate: | 02/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X |   |   | Y |   | Suppliers | Prosthetic/Orthotic Supplier |   |
No ID Information.