1861479016 NPI number — DURRETT'S ORTHOTIC AND PROSTHETIC LLC

Table of content: (NPI 1861479016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861479016 NPI number — DURRETT'S ORTHOTIC AND PROSTHETIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DURRETT'S ORTHOTIC AND PROSTHETIC 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:
1861479016
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 MEDICAL VILLAGE DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
EDGEWOOD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41017-5401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-341-7688
Provider Business Mailing Address Fax Number:
859-341-4476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 MEDICAL VILLAGE DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
EDGEWOOD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41017-5401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-341-7688
Provider Business Practice Location Address Fax Number:
859-341-4476
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WARD
Authorized Official First Name:
SUZIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
859-341-7688

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; 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: 8281414 . This is a "AETNA HMO" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000032033 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2433505000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: K002945 . This is a "CHAMPUS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 66634 . This is a "ABP-EDGEWOOD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 80444 . This is a "NORTHWOOD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: PO108 . This is a "CHOICE CARE/HUMANA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 0662831 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 427085 . This is a "CCN-ONE SOURCE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 45000312 . This is a "EPSDT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 100139 . This is a "KY HEALTH SELECT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1052964 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P0374 . This is a "HOMELINK" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 21755 . This is a "ABP-SOUTHGATE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 90420597 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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