Provider Demographics
NPI:1497425912
Name:CRANIAL PROSTHESIS SPECIALIST
Entity Type:Organization
Organization Name:CRANIAL PROSTHESIS SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GHYMINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-556-3923
Mailing Address - Street 1:5625 N GERMAN CHURCH RD # 3049
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46235-8513
Mailing Address - Country:US
Mailing Address - Phone:833-633-9447
Mailing Address - Fax:833-633-9447
Practice Address - Street 1:5126 N FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-2050
Practice Address - Country:US
Practice Address - Phone:317-556-3923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier