Healthcare Provider Details

I. General information

NPI: 1558323220
Provider Name (Legal Business Name): ORTHOTIC PROSTHETIC CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8330 PROFESSIONAL HILL DR
FAIRFAX VA
22031-4611
US

IV. Provider business mailing address

8330 PROFESSIONAL HILL DR
FAIRFAX VA
22031-4611
US

V. Phone/Fax

Practice location:
  • Phone: 703-698-5007
  • Fax: 703-207-9395
Mailing address:
  • Phone: 703-698-5007
  • Fax: 703-207-9395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MICHAEL CORCORAN
Title or Position: CEO
Credential: CPO
Phone: 301-906-0603