Provider Demographics
NPI:1811638208
Name:PROSTHETIX SHOP LLC
Entity type:Organization
Organization Name:PROSTHETIX SHOP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CONCETTA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-843-5126
Mailing Address - Street 1:2853 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:URBANCREST
Mailing Address - State:OH
Mailing Address - Zip Code:43123-1400
Mailing Address - Country:US
Mailing Address - Phone:614-500-4215
Mailing Address - Fax:614-500-4215
Practice Address - Street 1:2853 BROADWAY
Practice Address - Street 2:
Practice Address - City:URBANCREST
Practice Address - State:OH
Practice Address - Zip Code:43123-1400
Practice Address - Country:US
Practice Address - Phone:614-500-4215
Practice Address - Fax:614-500-4215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-07
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0081405Medicaid