=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104173053
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOBILE PROSTHETICS AND ORTHOTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2012
-----------------------------------------------------
Last Update Date | 04/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33374 DOWE AVE
-----------------------------------------------------
City | UNION CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94587-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-282-6898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33374 DOWE AVE
-----------------------------------------------------
City | UNION CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94587-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-282-6898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED ORTHOTIST
-----------------------------------------------------
Name | RICHARD ALI
-----------------------------------------------------
Credential | C.O
-----------------------------------------------------
Telephone | 510-282-6898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | CO004391
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------