Provider Demographics
NPI:1659692739
Name:ADAPT PROSTHETICS AND ORTHOTICS LLC
Entity Type:Organization
Organization Name:ADAPT PROSTHETICS AND ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCHER
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:208-765-0597
Mailing Address - Street 1:2204 IRONWOOD PL
Mailing Address - Street 2:STE A
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2662
Mailing Address - Country:US
Mailing Address - Phone:208-765-0597
Mailing Address - Fax:208-765-0598
Practice Address - Street 1:2204 IRONWOOD PL
Practice Address - Street 2:SUITE A
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2662
Practice Address - Country:US
Practice Address - Phone:208-765-0597
Practice Address - Fax:208-765-0598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-12
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1659692739Medicaid
6419450001OtherPTAN
6419450001OtherPTAN