Provider Demographics
NPI:1053378802
Name:FREMONT ARTIFICIAL LIMB & BRACE, INC.
Entity type:Organization
Organization Name:FREMONT ARTIFICIAL LIMB & BRACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CPO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:510-792-3475
Mailing Address - Street 1:1999 MOWRY AVE
Mailing Address - Street 2:SUITE J
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1723
Mailing Address - Country:US
Mailing Address - Phone:510-792-3475
Mailing Address - Fax:510-792-4864
Practice Address - Street 1:1999 MOWRY AVE
Practice Address - Street 2:SUITE J
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1723
Practice Address - Country:US
Practice Address - Phone:510-792-3475
Practice Address - Fax:510-792-4864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA004098335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000530Medicaid
CAGXC000530Medicaid