Provider Demographics
NPI:1619669793
Name:CREATIVE CUSTOM FOOT ORTHOTICS, LLC
Entity Type:Organization
Organization Name:CREATIVE CUSTOM FOOT ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:D
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:BOCPD
Authorized Official - Phone:303-669-3771
Mailing Address - Street 1:5500 E YALE AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-6930
Mailing Address - Country:US
Mailing Address - Phone:303-669-3771
Mailing Address - Fax:
Practice Address - Street 1:5500 E YALE AVE STE 110
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-6930
Practice Address - Country:US
Practice Address - Phone:303-669-3771
Practice Address - Fax:303-382-4600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment