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General NPI Number Information
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NPI Number | 1164892139
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Entity Type | Organization
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Legal Business Name | CROSSROADS ORTHOTICS AND PROSTHETICS LLC
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Dates
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Enumeration Date | 10/02/2015
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Last Update Date | 10/02/2015
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Provider Practice Location Address
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Address Line | 1137 VAN VOORHIS RD SUITE 15
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City | MORGANTOWN
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State | WV
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Zip | 26505-3453
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Country | US
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Telephone | 304-241-4094
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4112
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City | MORGANTOWN
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State | WV
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Zip | 26504-4112
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Country | US
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Telephone | 304-241-4094
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Fax |
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Authorized Official
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Title or Position | OWNER/CLINICAL DIRECTOR
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Name | THOMAS PACAK
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Credential | CPO
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Telephone | 304-241-4094
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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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