=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861146862
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABSOLUTE ORTHOTICS AND PROSTHETICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2022
-----------------------------------------------------
Last Update Date | 02/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 WEST RUSSELL STREET SUITE 102
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28301-5575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-484-4900
-----------------------------------------------------
Fax | 910-484-4908
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 WEST RUSSELL STREET SUITE 102
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28301-5575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-484-4900
-----------------------------------------------------
Fax | 910-484-4908
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. TRAVIS L DESSOFFY
-----------------------------------------------------
Credential | CPO
-----------------------------------------------------
Telephone | 910-484-4900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------