Provider Demographics
NPI:1275560518
Name:LIFE IN MOTION ORTHOTIC & PROSTHETIC CENTER, INC.
Entity Type:Organization
Organization Name:LIFE IN MOTION ORTHOTIC & PROSTHETIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, O & P PRACTICIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROLLE
Authorized Official - Suffix:
Authorized Official - Credentials:ABC CERTIFIED CP2919
Authorized Official - Phone:316-640-7267
Mailing Address - Street 1:PO BOX 55
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-0055
Mailing Address - Country:US
Mailing Address - Phone:316-640-7267
Mailing Address - Fax:620-225-0102
Practice Address - Street 1:443 N SAINT FRANCIS AVE STE E
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-2629
Practice Address - Country:US
Practice Address - Phone:316-640-7267
Practice Address - Fax:620-225-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS036F011744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS118318OtherBCBS KS
KS200405850AMedicaid
KS118318OtherBCBS KS