Healthcare Provider Details

I. General information

NPI: 1073651139
Provider Name (Legal Business Name): PREMIER ORTHOTIC AND PROSTHETIC SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N LARK ELLEN AVE STE I
WEST COVINA CA
91791-1099
US

IV. Provider business mailing address

855 N LARK ELLEN AVE STE I
WEST COVINA CA
91791-1099
US

V. Phone/Fax

Practice location:
  • Phone: 626-430-9253
  • Fax:
Mailing address:
  • Phone: 626-430-9253
  • Fax:

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. KEVIN M CAREY
Title or Position: PRESIDENT
Credential: CPO
Phone: 626-430-9253