1811264674 NPI number — MOBILE PROSTHETICS OF KENTUCKY

Table of content: TIMOTHY DONALD WRIGHT RPH (NPI 1326642596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811264674 NPI number — MOBILE PROSTHETICS OF KENTUCKY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOBILE PROSTHETICS OF KENTUCKY
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:
1811264674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 W MAIN ST
Provider Second Line Business Mailing Address:
STE E
Provider Business Mailing Address City Name:
CAMPBELLSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42718-2501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-465-8522
Provider Business Mailing Address Fax Number:
270-465-8523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
610 W MAIN ST
Provider Second Line Business Practice Location Address:
STE E
Provider Business Practice Location Address City Name:
CAMPBELLSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42718-2501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-465-8522
Provider Business Practice Location Address Fax Number:
270-465-8523
Provider Enumeration Date:
11/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
TONY
Authorized Official Middle Name:
GARRETT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
270-465-8522

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: 7100209830 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000788517 . This is a "ATHEM BLUE CROSS AND BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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