Provider Demographics
NPI:1518448638
Name:ADVANCED PROSTHETICS AND ORTHOTICS LLC
Entity Type:Organization
Organization Name:ADVANCED PROSTHETICS AND ORTHOTICS LLC
Other - Org Name:KORMYLO ORTHOPEDIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:WALKER
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-985-5190
Mailing Address - Street 1:904 S VANGUARD WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7552
Mailing Address - Country:US
Mailing Address - Phone:208-466-4360
Mailing Address - Fax:844-274-2789
Practice Address - Street 1:1070 N CURTIS RD STE 150
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1248
Practice Address - Country:US
Practice Address - Phone:208-377-4024
Practice Address - Fax:844-274-2789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-27
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty