Provider Demographics
NPI:1235194341
Name:POSITIVE IMAGE PROSTHETICS & ORTHOTICS, INC.
Entity type:Organization
Organization Name:POSITIVE IMAGE PROSTHETICS & ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:CPO/ LPO
Authorized Official - Phone:912-354-7500
Mailing Address - Street 1:POSITIVE IMAGE PROSTHETICS & ORTHOTICS, INC.
Mailing Address - Street 2:5202 WATERS AVE.
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6230
Mailing Address - Country:US
Mailing Address - Phone:912-354-7500
Mailing Address - Fax:912-354-7887
Practice Address - Street 1:POSITIVE IMAGE PROSTHETICS & ORTHOTICS, INC.
Practice Address - Street 2:5202 WATERS AVE.
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6230
Practice Address - Country:US
Practice Address - Phone:912-354-7500
Practice Address - Fax:912-354-7887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000844698AMedicaid
GA003212044AMedicaid
SCDE1986Medicaid
SCDE1986Medicaid