Provider Demographics
NPI:1548679897
Name:FUNCTIONAL ORTHOTICS & PROSTHETICS
Entity type:Organization
Organization Name:FUNCTIONAL ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:SEXON
Authorized Official - Last Name:WREGE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:505-200-9004
Mailing Address - Street 1:5111 JUAN TABO BLVD NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2672
Mailing Address - Country:US
Mailing Address - Phone:505-200-9004
Mailing Address - Fax:505-271-0217
Practice Address - Street 1:5111 JUAN TABO BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2672
Practice Address - Country:US
Practice Address - Phone:505-200-9004
Practice Address - Fax:505-271-0217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC49914335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier