MEDICARE: WILLAMETTE ORTHOTICS & PROSTHETICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1033307707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLAMETTE ORTHOTICS & PROSTHETICS LLC

Provider Business Mailing Address
First Line	:	PO BOX 7339
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97303-0102
Country	:	US
Telephone Number	:	503-364-6006
Fax Number	:

Provider Business Practice Location Address
First Line	:	3011 NE WEST DEVILS LAKE RD
Second Line	:
City	:	LINCOLN CITY
State	:	OR
Zip	:	97367-5131
Country	:	US
Telephone Number	:	541-996-9588
Fax Number	:	541-996-9588

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TODD J NELSON
Credential	:	CPO
Telephone Number	:	503-910-2073

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	04/17/2014

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