Provider Demographics
NPI:1689770554
Name:CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF KENTUCKY LLC
Entity Type:Organization
Organization Name:CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF KENTUCKY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REG COMPLIANCE SPECIALIST III
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGELINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-961-2102
Mailing Address - Street 1:P O BOX 650846
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1931 WEST ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-5039
Practice Address - Country:US
Practice Address - Phone:812-941-0966
Practice Address - Fax:812-941-0958
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANGER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-16
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INN/A335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90351560Medicaid
KY1050355Medicaid
IN1136130003OtherMEDICARE PTAN
IN200124260AMedicaid
KY90351560Medicaid