Provider Demographics
NPI:1174522015
Name:SPECTRUM ORTHOTICS & PROSTHETICS INC
Entity type:Organization
Organization Name:SPECTRUM ORTHOTICS & PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:E
Authorized Official - Last Name:CUZZORT
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:541-269-1773
Mailing Address - Street 1:1963 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2040
Mailing Address - Country:US
Mailing Address - Phone:541-269-1773
Mailing Address - Fax:541-269-2790
Practice Address - Street 1:1963 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2040
Practice Address - Country:US
Practice Address - Phone:541-269-1773
Practice Address - Fax:541-269-2790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR295418Medicaid
OR0942650003Medicare NSC