Provider Demographics
NPI:1306041306
Name:CERTIFIED PROSTHETICS ORTHOTICS, LLC
Entity Type:Organization
Organization Name:CERTIFIED PROSTHETICS ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-356-2123
Mailing Address - Street 1:1620 25TH AVE
Mailing Address - Street 2:STE A.
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4956
Mailing Address - Country:US
Mailing Address - Phone:970-356-2123
Mailing Address - Fax:970-352-4943
Practice Address - Street 1:1620 25TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4956
Practice Address - Country:US
Practice Address - Phone:970-356-2123
Practice Address - Fax:970-352-4943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO76431738Medicaid
CO5996540001Medicare NSC