Provider Demographics
NPI:1083944672
Name:CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF KY, LLC
Entity Type:Organization
Organization Name:CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF KY, LLC
Other - Org Name:CENTER FOR ORTHOTIC & PROSTHETIC CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REG COMPLIANCE SPECIALIST III
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGELINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-961-2102
Mailing Address - Street 1:P O BOX 650846
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 STONECREST RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8126
Practice Address - Country:US
Practice Address - Phone:502-899-9221
Practice Address - Fax:502-899-9468
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANGER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-05
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYNA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90351560Medicaid
IN200124260AMedicaid