Provider Demographics
NPI:1952961799
Name:PROFESSIONAL ORTHOTIC & PROSTHETIC SERVICES, LLC
Entity type:Organization
Organization Name:PROFESSIONAL ORTHOTIC & PROSTHETIC SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CP, BOCO
Authorized Official - Phone:785-375-7458
Mailing Address - Street 1:262 JOHNSON RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-1516
Mailing Address - Country:US
Mailing Address - Phone:785-320-5293
Mailing Address - Fax:
Practice Address - Street 1:919 WESTPORT PL
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2913
Practice Address - Country:US
Practice Address - Phone:785-320-2320
Practice Address - Fax:785-320-2321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-14
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSC50162OtherBOC
KSCP004340OtherABC