Provider Demographics
NPI:1740265495
Name:MID-MISSOURI ORTHOTICS & PROSTHETICS
Entity type:Organization
Organization Name:MID-MISSOURI ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-636-9611
Mailing Address - Street 1:3559 AMAZONAS DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5717
Mailing Address - Country:US
Mailing Address - Phone:573-636-9611
Mailing Address - Fax:573-636-9632
Practice Address - Street 1:3559 AMAZONAS DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5717
Practice Address - Country:US
Practice Address - Phone:573-636-9611
Practice Address - Fax:573-636-9632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO522024OtherHEALTHLINK
MO41486OtherHEALTHCARE USA
MO627800907Medicaid
MO166056OtherBLUE CROSS/BLUE SHIELD
MO627800907Medicaid