Healthcare Provider Details

I. General information

NPI: 1891300604
Provider Name (Legal Business Name): PIVOT PROSTHETICS AND ORTHOTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 S DOUGLAS HWY STE 130
GILLETTE WY
82718-5400
US

IV. Provider business mailing address

2007 S DOUGLAS HWY STE 130
GILLETTE WY
82718-5400
US

V. Phone/Fax

Practice location:
  • Phone: 307-696-8016
  • Fax: 307-206-8104
Mailing address:
  • Phone: 307-696-8016
  • Fax: 307-206-8104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRODIE RICE
Title or Position: OWNER
Credential: CPO
Phone: 307-670-0007