1265420616 NPI number — ROCKY MOUNTAIN ARTIFICIAL LIMB & BRACE, INC

Table of content: (NPI 1265420616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265420616 NPI number — ROCKY MOUNTAIN ARTIFICIAL LIMB & BRACE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROCKY MOUNTAIN ARTIFICIAL LIMB & BRACE, 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:
1265420616
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 WOODMONT BLVD
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-550-8774
Provider Business Mailing Address Fax Number:
615-454-5352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2230 E 25TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-3230
Provider Business Practice Location Address Fax Number:
208-524-3231
Provider Enumeration Date:
10/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
BRADFORD
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, COO
Authorized Official Telephone Number:
615-550-8760

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002498200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89748 . This is a "IF BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 071705 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 100005500 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89730 . This is a "POC BLUE CROSS ID#" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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