=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477077113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSTRIDE ORTHOTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2017
-----------------------------------------------------
Last Update Date | 10/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2610 GASKINS RD STE A
-----------------------------------------------------
City | HENRICO
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23238-1403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-310-3894
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5382
-----------------------------------------------------
City | GLEN ALLEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23058-5382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-310-3894
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDORTHIST
-----------------------------------------------------
Name | BHARTI MEHTA
-----------------------------------------------------
Credential | C.PED, CFO
-----------------------------------------------------
Telephone | 804-310-3894
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224L00000X
-----------------------------------------------------
Taxonomy Name | Pedorthist
-----------------------------------------------------
License Number | 4134
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------