1811264674 NPI number — MOBILE PROSTHETICS OF KENTUCKY

Table of content: (NPI 1811264674)

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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