Provider Demographics
NPI:1245838523
Name:PROSTHETIC CARE CLINIC LLC
Entity type:Organization
Organization Name:PROSTHETIC CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED ORTHOTIST PROSTHETIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-795-6438
Mailing Address - Street 1:812 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-2030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:812 MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-2030
Practice Address - Country:US
Practice Address - Phone:970-743-3118
Practice Address - Fax:707-433-1219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-09
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Single Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty