Provider Demographics
NPI:1053528828
Name:PACIFIC PEDORTHIC SERVICES
Entity type:Organization
Organization Name:PACIFIC PEDORTHIC SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:702-629-6818
Mailing Address - Street 1:106 S JONES BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2614
Mailing Address - Country:US
Mailing Address - Phone:702-629-6818
Mailing Address - Fax:702-993-8426
Practice Address - Street 1:106 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-2614
Practice Address - Country:US
Practice Address - Phone:702-629-6818
Practice Address - Fax:702-993-8426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9061110Medicaid
ID808067500Medicaid
WA9058868Medicaid
WA9061094Medicaid
WA5687630001Medicare NSC