Provider Demographics
NPI:1386646537
Name:ADVANCED ORTHOTICS AND PROSTHETICS
Entity Type:Organization
Organization Name:ADVANCED ORTHOTICS AND PROSTHETICS
Other - Org Name:ADVANCED O & P
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:W
Authorized Official - Last Name:IKERD
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:417-627-0999
Mailing Address - Street 1:2530 S MAIDEN LN
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-0349
Mailing Address - Country:US
Mailing Address - Phone:417-627-0999
Mailing Address - Fax:417-627-0938
Practice Address - Street 1:2530 S MAIDEN LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-0349
Practice Address - Country:US
Practice Address - Phone:417-627-0999
Practice Address - Fax:417-627-0938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO625367305Medicaid
MO625367305Medicaid