Provider Demographics
NPI:1154479798
Name:ORTHOTIC & PROSTHETIC LAB INC
Entity Type:Organization
Organization Name:ORTHOTIC & PROSTHETIC LAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-479-6298
Mailing Address - Street 1:125 N WEINBACH AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47711-6091
Mailing Address - Country:US
Mailing Address - Phone:812-479-6298
Mailing Address - Fax:812-479-6758
Practice Address - Street 1:125 N WEINBACH AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47711-6091
Practice Address - Country:US
Practice Address - Phone:812-479-6298
Practice Address - Fax:812-479-6758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100179970AMedicaid
IN100179970AMedicaid