Provider Demographics
NPI:1447329610
Name:SPECTRUM PROSTHETICS AND ORTHOTICS INC
Entity type:Organization
Organization Name:SPECTRUM PROSTHETICS AND ORTHOTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FOREST
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:SEXTON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:541-955-9678
Mailing Address - Street 1:300 UNION AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5861
Mailing Address - Country:US
Mailing Address - Phone:541-955-9678
Mailing Address - Fax:541-471-4909
Practice Address - Street 1:300 UNION AVE
Practice Address - Street 2:SUITE C
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5861
Practice Address - Country:US
Practice Address - Phone:541-955-9678
Practice Address - Fax:541-471-4909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR158752Medicaid
OR158752Medicaid