Healthcare Provider Details

I. General information

NPI: 1871255901
Provider Name (Legal Business Name): MOBILITY PROSTHETIC AND ORTHOTIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SHADOW LN STE 110
LAS VEGAS NV
89106-4355
US

IV. Provider business mailing address

400 SHADOW LN STE 110
LAS VEGAS NV
89106-4355
US

V. Phone/Fax

Practice location:
  • Phone: 702-800-6520
  • Fax: 702-800-6492
Mailing address:
  • Phone: 702-800-6520
  • 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: ILEA ALEXIS MATTISON
Title or Position: ADMINISTRATOR
Credential:
Phone: 928-377-4180