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General NPI Number Information
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NPI Number | 1043769169
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Entity Type | Organization
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Legal Business Name | MEDSOURCE ORTHOTICS & PROSTHETICS, INC
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Dates
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Enumeration Date | 09/30/2016
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Last Update Date | 09/14/2018
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Provider Practice Location Address
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Address Line | 13203 N 103RD AVE STE J1&J2
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City | SUN CITY
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State | AZ
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Zip | 85351
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Country | US
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Telephone | 602-395-3354
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Fax | 602-395-3361
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Provider Business Mailing Address
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Address Line | 3636 NORTH 3RD AVENUE SUITE 100
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City | PHOENIX
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State | AZ
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Zip | 85013-3904
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Country | US
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Telephone | 602-395-3354
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Fax | 602-395-3361
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Authorized Official
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Title or Position | PRESIDENT
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Name | DAVID CHARLES
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Credential |
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Telephone | 801-890-6824
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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