Healthcare Provider Details

I. General information

NPI: 1548545585
Provider Name (Legal Business Name): INNOVATIVE PROSTHETICS & ORTHOTICS OF GRAND ISLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 ALLEN DR
GRAND ISLAND NE
68803-3333
US

IV. Provider business mailing address

1213 ALLEN DR
GRAND ISLAND NE
68803-3333
US

V. Phone/Fax

Practice location:
  • Phone: 308-675-1508
  • Fax: 308-675-1509
Mailing address:
  • Phone: 308-675-1508
  • Fax: 308-675-1509

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: RAKESH SRIVASTAVA
Title or Position: OWNER
Credential:
Phone: 402-461-4931