Provider Demographics
NPI:1780686030
Name:EASTERN IOWA ORTHOTICS & PROSTHETICS, LLC
Entity Type:Organization
Organization Name:EASTERN IOWA ORTHOTICS & PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:HORSFALL
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:563-391-6789
Mailing Address - Street 1:5000 TREMONT AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1007
Mailing Address - Country:US
Mailing Address - Phone:563-391-6789
Mailing Address - Fax:563-391-4673
Practice Address - Street 1:5000 TREMONT AVE
Practice Address - Street 2:STE 201
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1007
Practice Address - Country:US
Practice Address - Phone:563-391-6789
Practice Address - Fax:563-391-4673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0443762Medicaid
IA5200040001Medicare NSC