MEDICARE: EAST SIDE 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

General Provider Information

NPI Number	:	1386599421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST SIDE ORTHOTICS & PROSTHETICS, INC.

Provider Business Mailing Address
First Line	:	17316 NE HALSEY ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97230-6026
Country	:	US
Telephone Number	:	503-257-6623
Fax Number	:	503-257-6624

Provider Business Practice Location Address
First Line	:	19767 SW 72ND AVE STE 102
Second Line	:
City	:	TUALATIN
State	:	OR
Zip	:	97062-8354
Country	:	US
Telephone Number	:	503-257-6623
Fax Number	:	503-257-6624

Authorized Official
Title or Position	:	CEO
Name	:	IVAN SABEL
Credential	:
Telephone Number	:	503-257-6623

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	05/12/2026

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