Provider Demographics
NPI:1952433971
Name:IDAHO PROSTHETICS & ORTHOTICS, INC.
Entity Type:Organization
Organization Name:IDAHO PROSTHETICS & ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-478-8800
Mailing Address - Street 1:333 N 18TH AVE STE B4
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3322
Mailing Address - Country:US
Mailing Address - Phone:208-478-8000
Mailing Address - Fax:208-478-8801
Practice Address - Street 1:333 N 18TH AVE STE B4
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3322
Practice Address - Country:US
Practice Address - Phone:208-478-8000
Practice Address - Fax:208-478-8801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805166100Medicaid
ID1203530001Medicare PIN
ID805166100Medicaid