=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053378802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREMONT ARTIFICIAL LIMB & BRACE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2006
-----------------------------------------------------
Last Update Date | 04/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1999 MOWRY AVE SUITE J
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-1723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-792-3475
-----------------------------------------------------
Fax | 510-792-4864
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1999 MOWRY AVE SUITE J
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-1723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-792-3475
-----------------------------------------------------
Fax | 510-792-4864
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / CPO
-----------------------------------------------------
Name | KENNETH ALLEN RASMUSSEN
-----------------------------------------------------
Credential | CPO
-----------------------------------------------------
Telephone | 510-792-3475
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 004098
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------