Healthcare Provider Details

I. General information

NPI: 1225628670
Provider Name (Legal Business Name): COMPLETE CARE PROSTHETICS AND ORTHOTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WASHINGTON AVE STE 18UC
PHILADELPHIA PA
19147-4836
US

IV. Provider business mailing address

600 WASHINGTON AVE STE 18UC
PHILADELPHIA PA
19147-4836
US

V. Phone/Fax

Practice location:
  • Phone: 215-298-0604
  • Fax: 215-298-0608
Mailing address:
  • Phone: 215-298-0604
  • Fax: 215-298-0608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: ABIODUN OLUWAGBENGA SOBOWALE
Title or Position: PROSTHETIST/ORTHOTIST
Credential: CPO
Phone: 215-298-0604