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General NPI Number Information
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NPI Number | 1154367548
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Entity Type | Organization
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Legal Business Name | WOOTEN PROSTHETICS INC
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Dates
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Enumeration Date | 06/22/2006
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Last Update Date | 09/12/2013
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Provider Practice Location Address
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Address Line | 203 MEDICAL WAY SUITE B
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City | RIVERDALE
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State | GA
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Zip | 30274-2517
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Country | US
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Telephone | 770-991-7128
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Fax | 770-991-7130
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Provider Business Mailing Address
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Address Line | 203 MEDICAL WAY SUITE B
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City | RIVERDALE
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State | GA
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Zip | 30274-2517
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Country | US
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Telephone | 770-991-7128
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Fax | 770-991-7130
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Authorized Official
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Title or Position | OWNER/CEO
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Name | MR. JAN L WOOTEN
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Credential | CP
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Telephone | 770-991-7128
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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 | N/A
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License Number State | GA
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