Provider Demographics
NPI:1053593129
Name:ADVANCED ORTHOTICS & PROSTHETICS CLINIC
Entity type:Organization
Organization Name:ADVANCED ORTHOTICS & PROSTHETICS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:601-649-0001
Mailing Address - Street 1:PO BOX 6501
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-6501
Mailing Address - Country:US
Mailing Address - Phone:601-649-0001
Mailing Address - Fax:601-649-0035
Practice Address - Street 1:434 S 13TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4345
Practice Address - Country:US
Practice Address - Phone:601-649-0001
Practice Address - Fax:601-649-0035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5276790001Medicare NSC
MS1053593129Medicare NSC