Provider Demographics
NPI:1265420616
Name:ROCKY MOUNTAIN ARTIFICIAL LIMB & BRACE, INC
Entity type:Organization
Organization Name:ROCKY MOUNTAIN ARTIFICIAL LIMB & BRACE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, COO
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-550-8760
Mailing Address - Street 1:102 WOODMONT BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205
Mailing Address - Country:US
Mailing Address - Phone:615-550-8774
Mailing Address - Fax:615-454-5352
Practice Address - Street 1:2230 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-524-3230
Practice Address - Fax:208-524-3231
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BULOW HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-10
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002498200Medicaid
ID89748OtherIF BLUE CROSS
ID071705OtherBLUE SHIELD
WY100005500Medicaid
ID89730OtherPOC BLUE CROSS ID#
ID89730OtherPOC BLUE CROSS ID#