Healthcare Provider Details

I. General information

NPI: 1669550695
Provider Name (Legal Business Name): BUCKEYE ORTHOPEDIC DESIGN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3187 WESTERN ROW RD SUITE 106
MAINEVILLE OH
45039-8045
US

IV. Provider business mailing address

3187 WESTERN ROW RD SUITE 106
MAINEVILLE OH
45039-8045
US

V. Phone/Fax

Practice location:
  • Phone: 513-770-5550
  • Fax: 513-770-4190
Mailing address:
  • Phone: 513-770-5550
  • Fax: 513-770-4190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberLPO 9
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberLPO 9
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberLPO 9
License Number StateOH

VIII. Authorized Official

Name: MR. MARK BONDURANT
Title or Position: PRESIDENT CLINICAL DIRECTOR
Credential: CPO, LPO
Phone: 513-770-5550