Healthcare Provider Details

I. General information

NPI: 1093350266
Provider Name (Legal Business Name): EAST SIDE ORTHOTICS & PROSTHETICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 MADISON ST
EUGENE OR
97402-5013
US

IV. Provider business mailing address

91 MADISON ST
EUGENE OR
97402-5013
US

V. Phone/Fax

Practice location:
  • Phone: 503-970-8388
  • Fax: 503-257-6624
Mailing address:
  • Phone: 503-970-8388
  • Fax: 503-257-6624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500778749
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: MR. BENJAMIN CLARK
Title or Position: OWNER/ CLINICIAN
Credential: CPO
Phone: 503-257-6623