Provider Demographics
NPI:1083668024
Name:PERSONAL IMAGE INC.
Entity Type:Organization
Organization Name:PERSONAL IMAGE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERSIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANNA
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:RFM
Authorized Official - Phone:316-260-8260
Mailing Address - Street 1:1905 N MAIZE RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-5203
Mailing Address - Country:US
Mailing Address - Phone:316-260-8260
Mailing Address - Fax:316-260-8266
Practice Address - Street 1:1905 N MAIZE RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-5203
Practice Address - Country:US
Practice Address - Phone:316-260-8260
Practice Address - Fax:316-260-8266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSCFM00705335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS5246400001Medicare NSC