Provider Demographics
NPI:1669507018
Name:ARKANSAS PROSTHETICS AND PEDORTHICS, INC
Entity Type:Organization
Organization Name:ARKANSAS PROSTHETICS AND PEDORTHICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:EDGAR
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:CP, C-PED
Authorized Official - Phone:501-860-6910
Mailing Address - Street 1:119 W CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3317
Mailing Address - Country:US
Mailing Address - Phone:501-860-6910
Mailing Address - Fax:501-860-7587
Practice Address - Street 1:119 W CARPENTER ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3317
Practice Address - Country:US
Practice Address - Phone:501-860-6910
Practice Address - Fax:501-860-7587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156100716Medicaid
AR49920OtherAR BLUECROSS BLUESHIELD
AR=========OtherTRICARE
AR=========OtherAR COMMUNTIY CARE
AR49920OtherAR BLUECROSS BLUESHIELD