1801942354 NPI number — IDAHO ORTHOTIC PROSTHETIC SERVICES, INC

Table of content: (NPI 1801942354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801942354 NPI number — IDAHO ORTHOTIC PROSTHETIC SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDAHO ORTHOTIC PROSTHETIC SERVICES, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801942354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8880 SW NIMBUS AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97008-7111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-765-5081
Provider Business Mailing Address Fax Number:
503-765-5081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 S WHITLEY DR STE 431
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-884-1294
Provider Business Practice Location Address Fax Number:
208-884-1293
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MORRISON
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
CONTRACT SPECIALIST
Authorized Official Telephone Number:
503-765-5081

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000010148826 . This is a "BLUE SHIELD IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8K537 . This is a "TRUE BLUE BLUE CROSS IDAH" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 807031400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 277882 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8K537 . This is a "BLUE CROSS IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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