Provider Demographics
NPI:1184831315
Name:LIFESTYLES ORTHOTICS AND PROSTHETICS
Entity Type:Organization
Organization Name:LIFESTYLES ORTHOTICS AND PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROOF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-393-2354
Mailing Address - Street 1:6157 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-2935
Mailing Address - Country:US
Mailing Address - Phone:402-561-0922
Mailing Address - Fax:402-561-0927
Practice Address - Street 1:6157 CENTER ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-2935
Practice Address - Country:US
Practice Address - Phone:402-561-0922
Practice Address - Fax:402-561-0927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0906123Medicaid
IA0906123Medicaid
IA0906123Medicaid