MEDICARE: TUCSON ORTHOPEDIC LAB LLC

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		AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BCBSAZ#0278440	OTHER	AZ	BCBS

General Provider Information

NPI Number	:	1932187218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TUCSON ORTHOPEDIC LAB LLC

Provider Business Mailing Address
First Line	:	PO BOX 43863
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85733-3863
Country	:	US
Telephone Number	:	520-319-0339
Fax Number	:	520-319-7825

Provider Business Practice Location Address
First Line	:	3818 E 5TH ST
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85716-5145
Country	:	US
Telephone Number	:	520-319-0339
Fax Number	:	520-319-7825

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DANNY CHAN
Credential	:	C.O.
Telephone Number	:	520-319-0339

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	11/24/2010

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