Healthcare Provider Details

I. General information

NPI: 1578937876
Provider Name (Legal Business Name): PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES-MIDWEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2015
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CONN TER
LEXINGTON KY
40508-3206
US

IV. Provider business mailing address

PO BOX 947109
ATLANTA GA
30394-7109
US

V. Phone/Fax

Practice location:
  • Phone: 859-268-5649
  • Fax: 859-268-5714
Mailing address:
  • Phone: 813-367-2876
  • Fax: 813-518-7659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberLPO-101
License Number StateKY

VIII. Authorized Official

Name: MR. ERIC LEE MILLER
Title or Position: MANAGER
Credential: CPO-L
Phone: 859-268-5708