Provider Demographics
NPI:1508852815
Name:SHOALS ORTHOTICS & PROSTHETICS,INC
Entity Type:Organization
Organization Name:SHOALS ORTHOTICS & PROSTHETICS,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPO,LPO
Authorized Official - Phone:256-764-8673
Mailing Address - Street 1:840 FLORENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-4871
Mailing Address - Country:US
Mailing Address - Phone:256-764-8673
Mailing Address - Fax:256-764-0872
Practice Address - Street 1:840 FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-4871
Practice Address - Country:US
Practice Address - Phone:256-764-8673
Practice Address - Fax:256-764-0872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
AL78997335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0071305OtherBCBS OF TENNESSEE
AL000054615Medicaid
AL51054615OtherBCBS OF ALABAMA
AL51054615OtherBCBS OF ALABAMA