Provider Demographics
NPI:1629089792
Name:FRONTIER ORTHOPEDIC SERVICES, PC
Entity Type:Organization
Organization Name:FRONTIER ORTHOPEDIC SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:BOCP
Authorized Official - Phone:307-637-3131
Mailing Address - Street 1:611 E. CARLSON STREET
Mailing Address - Street 2:SUITE 115
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4311
Mailing Address - Country:US
Mailing Address - Phone:307-637-3131
Mailing Address - Fax:307-637-4405
Practice Address - Street 1:611 E. CARLSON STREET
Practice Address - Street 2:SUITE 115
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4311
Practice Address - Country:US
Practice Address - Phone:307-637-3131
Practice Address - Fax:307-637-4405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYC12686335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY306400OtherBC/BS
WY119925100Medicaid
WY119925100Medicaid