Provider Demographics
NPI:1508804295
Name:SRT PROSTHETICS & ORTHOTICS LLC
Entity Type:Organization
Organization Name:SRT PROSTHETICS & ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEBENALER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-633-3961
Mailing Address - Street 1:408 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:IN
Mailing Address - Zip Code:46721-1179
Mailing Address - Country:US
Mailing Address - Phone:419-633-3961
Mailing Address - Fax:419-633-3981
Practice Address - Street 1:3818 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6840
Practice Address - Country:US
Practice Address - Phone:260-432-8886
Practice Address - Fax:260-432-1137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200360760Medicaid
IN21825OtherABP
IN000000229696OtherANTHEM
IN000000229696OtherANTHEM