Healthcare Provider Details

I. General information

NPI: 1295930600
Provider Name (Legal Business Name): FARTHEST NORTH PROSTHETICS AND ORTHOTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 12/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 INDUSTRIAL AVE
FAIRBANKS AK
99701-7376
US

IV. Provider business mailing address

3520 INDUSTRIAL AVE
FAIRBANKS AK
99701-7376
US

V. Phone/Fax

Practice location:
  • Phone: 907-455-9255
  • Fax: 907-455-6532
Mailing address:
  • Phone: 907-455-9255
  • Fax: 907-455-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberBL272686
License Number StateAK

VIII. Authorized Official

Name: RAYMOND GILLIGAN
Title or Position: PROSTHETIST ORTHOTIST
Credential:
Phone: 907-455-9255