Healthcare Provider Details

I. General information

NPI: 1003046137
Provider Name (Legal Business Name): ADVANCED ORTHOTIC DESIGNS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S STATE ST 602
OREM UT
84058-5419
US

IV. Provider business mailing address

105 S STATE ST 602
OREM UT
84058-5419
US

V. Phone/Fax

Practice location:
  • Phone: 801-226-1110
  • Fax:
Mailing address:
  • Phone: 801-226-1110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number12269678-002-STC
License Number StateUT

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MARK ALAN LATHAM
Title or Position: CEO
Credential:
Phone: 801-226-1110