Healthcare Provider Details

I. General information

NPI: 1861267460
Provider Name (Legal Business Name): DJO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2023
Last Update Date: 01/15/2024
Certification Date: 01/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 ELKHART RD STE B
GOSHEN IN
46526-1100
US

IV. Provider business mailing address

2020 ELKHART RD STE B
GOSHEN IN
46526-1100
US

V. Phone/Fax

Practice location:
  • Phone: 574-208-6702
  • Fax:
Mailing address:
  • Phone: 574-208-6702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. KIM TYRRELL-KNOTT
Title or Position: SVP, CHIEF COMPLIANCE OFFICER
Credential: JD
Phone: 866-356-7846