Provider Demographics
NPI:1417994500
Name:COLTRAIN, RICHARD SHANE (CPO)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:SHANE
Last Name:COLTRAIN
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 WH SMITH BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5052
Mailing Address - Country:US
Mailing Address - Phone:252-215-2215
Mailing Address - Fax:252-215-2216
Practice Address - Street 1:1025 WH SMITH BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5052
Practice Address - Country:US
Practice Address - Phone:252-215-2215
Practice Address - Fax:252-215-2216
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACPO 2469224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCABC CPO 2469OtherINDIVIDUAL ABC CERTIFICATION#
NC7795272Medicaid
NC0464JOtherNC BCBS PROVIDER#
NC5721020001Medicare NSC