Healthcare Provider Details

I. General information

NPI: 1306803218
Provider Name (Legal Business Name): CREATIVE ORTHOTIC LABORATORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8608 N 59TH AVE
GLENDALE AZ
85302-5404
US

IV. Provider business mailing address

8608 N 59TH AVE
GLENDALE AZ
85302-5404
US

V. Phone/Fax

Practice location:
  • Phone: 623-934-3213
  • Fax: 623-930-1891
Mailing address:
  • Phone: 623-934-3213
  • Fax: 623-930-1891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARK RICHARD GORMAN
Title or Position: C.E.O.
Credential: D.P.M.
Phone: 623-934-3213