MEDICARE: LEDU'S PEDORTHIC SERVICES

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	332BC3200X	Customized Equipment (DME)	45656	CA

General Provider Information

NPI Number	:	1184819013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEDU'S PEDORTHIC SERVICES

Provider Business Mailing Address
First Line	:	215 S 5TH ST
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-3012
Country	:	US
Telephone Number	:	760-352-3336
Fax Number	:	760-352-3271

Provider Business Practice Location Address
First Line	:	215 S 5TH ST
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-3012
Country	:	US
Telephone Number	:	760-352-3336
Fax Number	:	760-352-3271

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ROBERTO D LOPEZ
Credential	:
Telephone Number	:	760-352-3336

Provider Enumeration Date	:	09/13/2007
Last Update Date	:	09/13/2007

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