Healthcare Provider Details

I. General information

NPI: 1275605461
Provider Name (Legal Business Name): MEDSOURCE ORTHOTICS & PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9305 W. THOMAS RD SUITE 150
PHOENIX AZ
85037
US

IV. Provider business mailing address

3636 N 3RD AVE STE 100
PHOENIX AZ
85013-3938
US

V. Phone/Fax

Practice location:
  • Phone: 623-738-0301
  • Fax: 602-395-3361
Mailing address:
  • Phone: 602-395-3354
  • Fax: 602-395-3361

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: DAVID CHARLES
Title or Position: PRESIDENT
Credential:
Phone: 801-255-5202