Healthcare Provider Details

I. General information

NPI: 1104859248
Provider Name (Legal Business Name): PROSTHETIC DEVELOPMENT AND RESEARCH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MERCADO ST STE. 203
DURANGO CO
81301-7300
US

IV. Provider business mailing address

1 MERCADO ST STE. 203
DURANGO CO
81301-7300
US

V. Phone/Fax

Practice location:
  • Phone: 970-259-9258
  • Fax: 970-385-7262
Mailing address:
  • Phone: 970-259-9258
  • Fax: 970-385-7262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number1428
License Number StateIL

VIII. Authorized Official

Name: MR. TIMOTHY JOHN OBRIEN
Title or Position: PRESIDENT
Credential: C.P.O.
Phone: 970-259-9258