Healthcare Provider Details

I. General information

NPI: 1013440932
Provider Name (Legal Business Name): ESSENTIAL ORTHOTICS AND PROSTHETICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 06/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 GRAND CYPRESS AVE SUITE 304
PALMDALE CA
93551-3646
US

IV. Provider business mailing address

360 GRAND CYPRESS AVENUE SUITE 304
PALMDALE CA
93551-1416
US

V. Phone/Fax

Practice location:
  • Phone: 661-723-3700
  • Fax: 661-723-3799
Mailing address:
  • Phone: 661-723-3700
  • Fax: 661-723-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number32836
License Number StateCA

VIII. Authorized Official

Name: MICHAEL J METICHECCHIA
Title or Position: CEO
Credential: CPO
Phone: 661-886-5828