Provider Demographics
NPI:1245575570
Name:SNELL PROSTHETIC & ORTHOTIC LABORATORY
Entity Type:Organization
Organization Name:SNELL PROSTHETIC & ORTHOTIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BRANT
Authorized Official - Middle Name:E
Authorized Official - Last Name:SNELL
Authorized Official - Suffix:
Authorized Official - Credentials:LOPA
Authorized Official - Phone:501-664-2624
Mailing Address - Street 1:2915 DAVE WARD DR STE 11
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-9375
Mailing Address - Country:US
Mailing Address - Phone:501-548-6288
Mailing Address - Fax:501-513-1890
Practice Address - Street 1:2915 DAVE WARD DR STE 11
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-9375
Practice Address - Country:US
Practice Address - Phone:501-548-6288
Practice Address - Fax:501-513-1890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR299159716Medicaid