Healthcare Provider Details

I. General information

NPI: 1588085278
Provider Name (Legal Business Name): ALPHA-OMEGA ORTHOTICS & PROSTHETICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2013
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 E DRAKE ST
BOLIVAR MO
65613-2739
US

IV. Provider business mailing address

2021 S WAVERLY AVE SUITE 300
SPRINGFIELD MO
65804-2414
US

V. Phone/Fax

Practice location:
  • Phone: 417-886-8881
  • Fax: 417-881-8223
Mailing address:
  • Phone: 417-886-8881
  • Fax: 417-881-8223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberBUS-0027960
License Number StateMO

VIII. Authorized Official

Name: MR. RONALD VAHL
Title or Position: PRESIDENT
Credential: CPO
Phone: 417-886-8881