Provider Demographics
NPI:1770774499
Name:CENTER FOR PROSTHETICS ORTHOTICS, INC.
Entity type:Organization
Organization Name:CENTER FOR PROSTHETICS ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:IGNACIO
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:206-328-4276
Mailing Address - Street 1:411 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5577
Mailing Address - Country:US
Mailing Address - Phone:206-328-4276
Mailing Address - Fax:206-328-1037
Practice Address - Street 1:12911 120TH AVE NE STE E60
Practice Address - Street 2:C/O EVERGREEN PROFESSIONAL PLAZA
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3047
Practice Address - Country:US
Practice Address - Phone:425-821-4276
Practice Address - Fax:425-821-4277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS00000002335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9015561Medicaid
WA0285850003Medicare NSC