Provider Demographics
NPI:1477769784
Name:FOOTHILLS PROSTHETICS LLC
Entity Type:Organization
Organization Name:FOOTHILLS PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WICKER
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:828-391-5164
Mailing Address - Street 1:1603 S STERLING ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-4097
Mailing Address - Country:US
Mailing Address - Phone:828-391-5164
Mailing Address - Fax:828-391-5011
Practice Address - Street 1:1603 S STERLING ST
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-4097
Practice Address - Country:US
Practice Address - Phone:828-391-5164
Practice Address - Fax:828-391-5011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704693Medicaid
NC5933630001Medicare NSC