Provider Demographics
NPI:1629301619
Name:COLUMBIA BASIN PROSTHETICS & ORTHOTICS, INC
Entity Type:Organization
Organization Name:COLUMBIA BASIN PROSTHETICS & ORTHOTICS, INC
Other - Org Name:PROSTHETIC & ORTHOTIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPOA
Authorized Official - Phone:509-525-8322
Mailing Address - Street 1:PO BOX 662
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0016
Mailing Address - Country:US
Mailing Address - Phone:509-525-8322
Mailing Address - Fax:509-525-2982
Practice Address - Street 1:919 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2746
Practice Address - Country:US
Practice Address - Phone:509-525-8322
Practice Address - Fax:509-525-2982
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLUMBIA BASIN PROSTHETICS & ORTHOTICS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-09
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9035353Medicaid
OR500619060Medicaid
OR500619060Medicaid