1578699393 NPI number — KENDALL PROSTHETICS & ORTHOTICS, INC.

Table of content: (NPI 1578699393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578699393 NPI number — KENDALL PROSTHETICS & ORTHOTICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENDALL PROSTHETICS & ORTHOTICS, 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:
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:
1578699393
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3012 LAKE WASHINGTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32934-7613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-622-5140
Provider Business Mailing Address Fax Number:
616-825-6139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3012 LAKE WASHINGTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32934-7613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-622-5140
Provider Business Practice Location Address Fax Number:
616-825-6139
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ODELL
Authorized Official First Name:
TODD
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
321-622-5140

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  POR5 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 226307 . This is a "AVMED HEALTH PLANS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 951163600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 169843900 . This is a "U.S. DEPT. OF LABOR OWCP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: M2289 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 116274000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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