Provider Demographics
NPI:1780303883
Name:DURRETT'S ORTHOTIC AND PROSTHETIC LLC
Entity type:Organization
Organization Name:DURRETT'S ORTHOTIC AND PROSTHETIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-341-7688
Mailing Address - Street 1:20 MEDICAL VILLAGE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5403
Mailing Address - Country:US
Mailing Address - Phone:859-341-7688
Mailing Address - Fax:
Practice Address - Street 1:1049 W EADS PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-1162
Practice Address - Country:US
Practice Address - Phone:812-489-7304
Practice Address - Fax:812-489-7320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-23
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300064747Medicaid