Provider Demographics
NPI:1235571811
Name:CERTIFIED PROSTHETICS & ORTHOTICS, LLC
Entity Type:Organization
Organization Name:CERTIFIED PROSTHETICS & ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-635-3700
Mailing Address - Street 1:2621 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-1745
Mailing Address - Country:US
Mailing Address - Phone:308-635-3700
Mailing Address - Fax:308-635-3709
Practice Address - Street 1:2621 5TH AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-1745
Practice Address - Country:US
Practice Address - Phone:308-635-3700
Practice Address - Fax:308-635-3709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10561404335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025756000Medicaid