=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609309889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RELIABLE ORTHOTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2017
-----------------------------------------------------
Last Update Date | 08/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9950 W VAN BUREN ST STE 137
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-5320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-223-9179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9950 W VAN BUREN ST STE 137
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-5320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-223-9179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHELSEA BURRUSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-223-9179
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------