1801942354 NPI number — IDAHO ORTHOTIC PROSTHETIC SERVICES, INC

Table of Contents

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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