Provider Demographics
NPI:1184831349
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 1:6751 N 72ND ST STE 201
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-1746
Mailing Address - Country:US
Mailing Address - Phone:402-572-2233
Mailing Address - Fax:402-572-2270
Practice Address - Street 1:6940 VAN DORN ST STE 101
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-2858
Practice Address - Country:US
Practice Address - Phone:402-483-5955
Practice Address - Fax:402-483-7396
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
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0541458Medicaid
IA0541458Medicaid
IA0541458Medicaid