Healthcare Provider Details

I. General information

NPI: 1629027560
Provider Name (Legal Business Name): SHIELDS ORTHOTIC PROSTHETIC SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5687 HARRISON BLVD
SOUTH OGDEN UT
84403-4322
US

IV. Provider business mailing address

2785 E 3300 S
SALT LAKE CITY UT
84109-2818
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-4428
  • Fax: 801-475-0427
Mailing address:
  • Phone: 801-467-5483
  • Fax: 801-484-4591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MS. SHERYL S PRICE
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 503-493-8288