Provider Demographics
NPI:1124209820
Name:ORTHOPRO OF LEWISTON INC
Entity Type:Organization
Organization Name:ORTHOPRO OF LEWISTON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:208-798-0200
Mailing Address - Street 1:823 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3733
Mailing Address - Country:US
Mailing Address - Phone:208-798-0200
Mailing Address - Fax:208-798-0201
Practice Address - Street 1:823 16TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3733
Practice Address - Country:US
Practice Address - Phone:208-798-0200
Practice Address - Fax:208-798-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807553700Medicaid