Provider Demographics
NPI:1427033695
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 1:625 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-2917
Mailing Address - Country:US
Mailing Address - Phone:501-664-2624
Mailing Address - Fax:501-664-1708
Practice Address - Street 1:333 HIGHWAY 5 N
Practice Address - Street 2:SUITE 4
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3026
Practice Address - Country:US
Practice Address - Phone:870-424-7010
Practice Address - Fax:870-424-6316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-10
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR04734178001335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR299148716Medicaid