1083944672 NPI number — CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF KY, LLC

Table of content: (NPI 1083944672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083944672 NPI number — CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF KY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF KY, LLC
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:
6
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:
1083944672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 650846
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75265-0846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 STONECREST RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40065-8126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-899-9221
Provider Business Practice Location Address Fax Number:
502-899-9468
Provider Enumeration Date:
01/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ANGELINE
Authorized Official First Name:
GRACE
Authorized Official Middle Name:
Authorized Official Title or Position:
REG COMPLIANCE SPECIALIST III
Authorized Official Telephone Number:
714-961-2102

Provider Taxonomy Codes

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

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

  • Identifier: 90351560 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200124260A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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