1699712695 NPI number — SRT PROSTHETICS & ORTHOTICS LLC

Table of content: (NPI 1699712695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699712695 NPI number — SRT PROSTHETICS & ORTHOTICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SRT PROSTHETICS & ORTHOTICS 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:
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:
1699712695
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 E WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUTLER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46721-1179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-633-3961
Provider Business Mailing Address Fax Number:
419-633-3981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 E SOUTHWAY BLVD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KOKOMO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46902-3577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-865-3668
Provider Business Practice Location Address Fax Number:
765-865-9640
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SIEBENALER
Authorized Official First Name:
LESLIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
866-633-3961

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)





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