Healthcare Provider Details

I. General information

NPI: 1912283953
Provider Name (Legal Business Name): CREATIVE ORTHOTIC LABS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2011
Last Update Date: 10/21/2011
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 Number20519930X
License Number StateAZ

VIII. Authorized Official

Name: MRS. SHERRI LYNN HAZELWOOD
Title or Position: PRESIDENT
Credential:
Phone: 623-934-3213