MEDICARE: SPECTRUM ORTHOTICS & PROSTHETICS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier		OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174522015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECTRUM ORTHOTICS & PROSTHETICS INC

Provider Business Mailing Address
First Line	:	1963 THOMPSON RD
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2040
Country	:	US
Telephone Number	:	541-269-1773
Fax Number	:	541-269-2790

Provider Business Practice Location Address
First Line	:	1963 THOMPSON RD
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2040
Country	:	US
Telephone Number	:	541-269-1773
Fax Number	:	541-269-2790

Authorized Official
Title or Position	:	OWNER
Name	:	JOSEPH E CUZZORT
Credential	:	CP
Telephone Number	:	541-269-1773

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	01/06/2015

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