Healthcare Provider Details

I. General information

NPI: 1992249718
Provider Name (Legal Business Name): XTREME PROSTHETICS LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S BROADWAY ST
GLASGOW KY
42141-2502
US

IV. Provider business mailing address

400 S BROADWAY ST
GLASGOW KY
42141-2502
US

V. Phone/Fax

Practice location:
  • Phone: 270-629-5462
  • Fax:
Mailing address:
  • Phone: 270-629-5462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number135770
License Number StateKY

VIII. Authorized Official

Name: MR. AARON E KRATOHVIL JR.
Title or Position: MANAGING MEMBER
Credential: CPO
Phone: 615-550-8760