Healthcare Provider Details

I. General information

NPI: 1548679897
Provider Name (Legal Business Name): FUNCTIONAL ORTHOTICS & PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 JUAN TABO BLVD NE STE A
ALBUQUERQUE NM
87111-2672
US

IV. Provider business mailing address

5111 JUAN TABO BLVD NE STE A
ALBUQUERQUE NM
87111-2672
US

V. Phone/Fax

Practice location:
  • Phone: 505-200-9004
  • Fax: 505-271-0217
Mailing address:
  • Phone: 505-200-9004
  • Fax: 505-271-0217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberC49914
License Number StateMD

VIII. Authorized Official

Name: MR. STEVEN SEXON WREGE
Title or Position: PRESIDENT/OWNER
Credential: DPM
Phone: 505-200-9004