Healthcare Provider Details

I. General information

NPI: 1922104751
Provider Name (Legal Business Name): FONTANA ARTIFICIAL LIMB & BRACE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8576 NUEVO AVE
FONTANA CA
92335-3826
US

IV. Provider business mailing address

8576 NUEVO AVE
FONTANA CA
92335-3826
US

V. Phone/Fax

Practice location:
  • Phone: 909-822-3233
  • Fax: 909-822-6480
Mailing address:
  • Phone: 909-822-3233
  • Fax: 909-822-6480

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: MR. JEFFREY WAYNE WOOD
Title or Position: PRESIDENT / CERTIFIED PROSTHETIST
Credential:
Phone: 909-822-3233