Healthcare Provider Details

I. General information

NPI: 1760119168
Provider Name (Legal Business Name): CENTRAL ORTHOTIC & PROSTHETIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2039 N FINE AVE
FRESNO CA
93727-1512
US

IV. Provider business mailing address

2039 N FINE AVE
FRESNO CA
93727-1512
US

V. Phone/Fax

Practice location:
  • Phone: 559-251-5557
  • Fax:
Mailing address:
  • Phone: 559-251-5557
  • 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 Code222Z00000X
TaxonomyOrthotist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateNULL

VIII. Authorized Official

Name: RANDY S VALLEMBOIS
Title or Position: OWNER
Credential: CPO
Phone: 559-776-8512