Provider Demographics
NPI:1245378074
Name:PROSTHETICS ETC., INC.
Entity type:Organization
Organization Name:PROSTHETICS ETC., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CAREY
Authorized Official - Suffix:
Authorized Official - Credentials:CPO, FAAOP
Authorized Official - Phone:714-502-9354
Mailing Address - Street 1:1700 E LINCOLN AVE
Mailing Address - Street 2:101
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-4323
Mailing Address - Country:US
Mailing Address - Phone:714-502-9354
Mailing Address - Fax:714-502-9455
Practice Address - Street 1:1700 E LINCOLN AVE
Practice Address - Street 2:101
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-4323
Practice Address - Country:US
Practice Address - Phone:714-502-9354
Practice Address - Fax:714-502-9455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0009041Medicaid
CAXC0009041Medicaid