Healthcare Provider Details

I. General information

NPI: 1184205379
Provider Name (Legal Business Name): SUMMIT CITY PROSTHETICS & ORTHOTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16597 STATE ROAD 23 STE 2
SOUTH BEND IN
46635-1461
US

IV. Provider business mailing address

16597 STATE ROAD 23 STE 2
SOUTH BEND IN
46635-1461
US

V. Phone/Fax

Practice location:
  • Phone: 574-855-1488
  • Fax: 574-387-5583
Mailing address:
  • Phone: 574-855-1488
  • Fax: 574-387-5583

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. SHAWN DEE BROWN
Title or Position: PRESIDENT
Credential: CPO
Phone: 260-312-1746