Healthcare Provider Details

I. General information

NPI: 1578548426
Provider Name (Legal Business Name): LAKE NORMAN ORTHOTICS & PROSTHETICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 S HIGHWAY 16
STANLEY NC
28164-8709
US

IV. Provider business mailing address

1095 S HIGHWAY 16
STANLEY NC
28164-8709
US

V. Phone/Fax

Practice location:
  • Phone: 704-822-8005
  • Fax: 704-822-8828
Mailing address:
  • Phone: 704-822-8005
  • Fax: 704-822-8828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number2673
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7703034
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier046AJ
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS
# 3
Identifier6487083
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerCIGNA

VIII. Authorized Official

Name: MR. KURT F BEYER
Title or Position: OWNER
Credential: C.P.O.
Phone: 704-822-8005