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General NPI Number Information
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NPI Number | 1720253305
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Entity Type | Organization
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Legal Business Name | CORE PROSTHETICS LAB, INC.
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Dates
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Enumeration Date | 04/24/2008
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Last Update Date | 11/19/2009
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Provider Practice Location Address
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Address Line | 29723 NEW HUB DR STE A
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City | SUN CITY
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State | CA
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Zip | 92586-6537
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Country | US
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Telephone | 951-246-8888
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Fax | 951-246-8675
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Provider Business Mailing Address
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Address Line | 29723 NEW HUB DR STE A
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City | SUN CITY
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State | CA
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Zip | 92586-6537
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Country | US
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Telephone | 951-246-8888
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Fax | 951-246-8675
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Authorized Official
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Title or Position | MANAGER
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Name | TUTY IRIANTO
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Credential | CFM01267
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Telephone | 951-246-8888
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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 | CFM01267
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License Number State | DE
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Taxonomy #2
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | P1115
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License Number State | DE
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