Healthcare Provider Details

I. General information

NPI: 1265554984
Provider Name (Legal Business Name): SPECTRUM PROSTHETICS AND ORTHOTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 UNION AVE STE C
GRANTS PASS OR
97527-5861
US

IV. Provider business mailing address

300 UNION AVE SUITE C
GRANTS PASS OR
97527-5861
US

V. Phone/Fax

Practice location:
  • Phone: 541-955-9678
  • Fax: 541-471-4909
Mailing address:
  • Phone: 541-955-9678
  • Fax: 541-471-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberNA
License Number State

VII. Legacy identifiers

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

# 1
Identifier500637334
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: MR. FOREST RAY SEXTON
Title or Position: DIRECTOR
Credential: CPO
Phone: 541-734-2435