Healthcare Provider Details

I. General information

NPI: 1285852004
Provider Name (Legal Business Name): CLEARWATER ORTHOTICS AND PROSTHETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BRYDEN AVE
LEWISTON ID
83501-4927
US

IV. Provider business mailing address

PO BOX 2620
HAYDEN ID
83835-2620
US

V. Phone/Fax

Practice location:
  • Phone: 208-798-4605
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: KAREN HALE
Title or Position: OFFICE MANAGER
Credential:
Phone: 818-357-5732