=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184831349
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESTYLES ORTHOTICS AND PROSTHETICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6940 VAN DORN ST STE 101
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68506-2858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-483-5955
-----------------------------------------------------
Fax | 402-483-7396
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6751 N 72ND ST STE 201
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68122-1746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-572-2233
-----------------------------------------------------
Fax | 402-572-2270
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADM MANAGER
-----------------------------------------------------
Name | SHIRLEY ROOF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-393-2354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------