Provider Demographics
NPI:1023379377
Name:KOOTENAI PROSTHETIC ORTHOTIC SERVICES INC
Entity Type:Organization
Organization Name:KOOTENAI PROSTHETIC ORTHOTIC SERVICES INC
Other - Org Name:KOOTENAI PROSTHETICS ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CPO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCPO
Authorized Official - Phone:208-457-1545
Mailing Address - Street 1:1160 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6045
Mailing Address - Country:US
Mailing Address - Phone:208-457-1545
Mailing Address - Fax:208-457-1659
Practice Address - Street 1:1160 E POLSTON AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6045
Practice Address - Country:US
Practice Address - Phone:208-457-1545
Practice Address - Fax:208-457-1659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-04
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0336590004Medicare NSC