Healthcare Provider Details

I. General information

NPI: 1124209820
Provider Name (Legal Business Name): ORTHOPRO OF LEWISTON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 16TH AVE
LEWISTON ID
83501-3733
US

IV. Provider business mailing address

823 16TH AVE
LEWISTON ID
83501-3733
US

V. Phone/Fax

Practice location:
  • Phone: 208-798-0200
  • Fax: 208-798-0201
Mailing address:
  • Phone: 208-798-0200
  • Fax: 208-798-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. MARSHALL R BLACK
Title or Position: OWNER
Credential: CPO
Phone: 208-798-0200