Provider Demographics
NPI:1578699393
Name:KENDALL PROSTHETICS & ORTHOTICS, INC.
Entity Type:Organization
Organization Name:KENDALL PROSTHETICS & ORTHOTICS, INC.
Other - Org Name:INTEGRATIVE REHABILITATION MEDICAL, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:ODELL
Authorized Official - Suffix:
Authorized Official - Credentials:COF
Authorized Official - Phone:321-622-5140
Mailing Address - Street 1:3012 LAKE WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7613
Mailing Address - Country:US
Mailing Address - Phone:321-622-5140
Mailing Address - Fax:616-825-6139
Practice Address - Street 1:3012 LAKE WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7613
Practice Address - Country:US
Practice Address - Phone:321-622-5140
Practice Address - Fax:616-825-6139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR5335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL226307OtherAVMED HEALTH PLANS
FL951163600Medicaid
FL169843900OtherU.S. DEPT. OF LABOR OWCP
FLM2289OtherBLUE CROSS BLUE SHEILD
FL169843900OtherU.S. DEPT. OF LABOR OWCP
FLM2289OtherBLUE CROSS BLUE SHEILD
FL951163600Medicaid