Healthcare Provider Details

I. General information

NPI: 1780459388
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: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 COUNTY ROAD D W STE 110
SAINT PAUL MN
55112-8503
US

IV. Provider business mailing address

2900 LAKE VISTA DR STE 200
LEWISVILLE TX
75067-3889
US

V. Phone/Fax

Practice location:
  • Phone: 612-445-9191
  • Fax: 844-277-2075
Mailing address:
  • Phone: 704-749-6291
  • Fax: 704-831-8300

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: MR. ANDRES MORENO III
Title or Position: GOVERNMENT PAYOR RELATIONS ADVISOR
Credential:
Phone: 704-749-6291