Provider Demographics
NPI:1225403942
Name:CENTER FOR ORTHOTICS AND PROSTHETICS INC.
Entity Type:Organization
Organization Name:CENTER FOR ORTHOTICS AND PROSTHETICS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:R
Authorized Official - Last Name:STEELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-757-5461
Mailing Address - Street 1:6655 QUINCE RD
Mailing Address - Street 2:STE 124
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8031
Mailing Address - Country:US
Mailing Address - Phone:901-757-5461
Mailing Address - Fax:
Practice Address - Street 1:2321 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2213
Practice Address - Country:US
Practice Address - Phone:662-243-7435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-07
Last Update Date:2019-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN335E00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02324535Medicaid