Provider Demographics
NPI:1770566499
Name:MID-MISSOURI ORTHOTICS & PROSTHETICS
Entity type:Organization
Organization Name:MID-MISSOURI ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-449-3859
Mailing Address - Street 1:1101 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-4659
Mailing Address - Country:US
Mailing Address - Phone:573-817-1782
Mailing Address - Fax:573-449-7593
Practice Address - Street 1:1101 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-4659
Practice Address - Country:US
Practice Address - Phone:573-817-1782
Practice Address - Fax:573-449-7593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO166056OtherBLUE CROSS PROVIDER NUMBE
MO41486OtherHEALTHCARE USA PROVIDER N
MO522024OtherHEALTHLINK PROVIDER NUMBE
MO41486OtherHEALTHCARE USA PROVIDER N