Healthcare Provider Details

I. General information

NPI: 1104014877
Provider Name (Legal Business Name): WILLAMETTE ORTHOTICS & PROSTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE NEFF RD STE 307
BEND OR
97701-4279
US

IV. Provider business mailing address

PO BOX 7339
SALEM OR
97303-0102
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-5422
  • Fax: 541-389-7656
Mailing address:
  • Phone: 503-364-6006
  • Fax: 503-364-6046

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: TODD J NELSON
Title or Position: PRESIDENT
Credential: CPO
Phone: 503-364-6006