Provider Demographics
NPI:1649203670
Name:CHARLESTON ORTHOPEDIC APPLIANCES INC
Entity Type:Organization
Organization Name:CHARLESTON ORTHOPEDIC APPLIANCES INC
Other - Org Name:CHARLESTON ORTHPEDIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CECIL
Authorized Official - Middle Name:A
Authorized Official - Last Name:TANKERSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CO,BOCO,C-PED,RTO
Authorized Official - Phone:304-343-8994
Mailing Address - Street 1:1532 KANAWHA BLVD W
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25312-2533
Mailing Address - Country:US
Mailing Address - Phone:304-343-8994
Mailing Address - Fax:304-720-2078
Practice Address - Street 1:1532 KANAWHA BLVD W
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312-2533
Practice Address - Country:US
Practice Address - Phone:304-343-8994
Practice Address - Fax:304-720-2078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVNOT APPLICABLE335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2417067Medicaid
WV0148049000Medicaid
WV000201174OtherBLUE CROSS & BLUE SHIELD
WV0148049000Medicaid