Healthcare Provider Details

I. General information

NPI: 1285330696
Provider Name (Legal Business Name): ROADRUNNER PROSTHETICS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42212 N 41ST DR STE 105
ANTHEM AZ
85086-3815
US

IV. Provider business mailing address

42212 N 41ST DR STE 105
ANTHEM AZ
85086-3815
US

V. Phone/Fax

Practice location:
  • Phone: 623-352-4520
  • Fax:
Mailing address:
  • Phone: 623-352-4520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MACKINLEY SPENCER BURRELL
Title or Position: PROSTHETIST
Credential: C.P.
Phone: 512-922-4620