1649499690 NPI number — SKY PROSTHETICS INC

Table of content: ANGELA KELLY CRISMAN MA (NPI 1194296756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649499690 NPI number — SKY PROSTHETICS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SKY PROSTHETICS 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:
1649499690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
503 CHIEF ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENKELMAN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69021-3065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-423-2690
Provider Business Mailing Address Fax Number:
308-423-2691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
503 CHIEF ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENKELMAN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69021-3065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-423-2690
Provider Business Practice Location Address Fax Number:
308-423-2691
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLECHA
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
308-423-2690

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  CPO 2571 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100025425600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1659570 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000118447 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 09904 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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