Provider Demographics
NPI:1861492621
Name:COLORADO ORTHOTIC & PROSTHETIC SERVICES, LLC
Entity Type:Organization
Organization Name:COLORADO ORTHOTIC & PROSTHETIC SERVICES, LLC
Other - Org Name:EVERGREEN PROSTHETICS AND ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-407-5408
Mailing Address - Street 1:911 MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1853
Mailing Address - Country:US
Mailing Address - Phone:503-765-5081
Mailing Address - Fax:971-316-1553
Practice Address - Street 1:128 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-5105
Practice Address - Country:US
Practice Address - Phone:720-685-6520
Practice Address - Fax:720-685-6521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67632751Medicaid
4479040002Medicare NSC