=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235571811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CERTIFIED PROSTHETICS & ORTHOTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2013
-----------------------------------------------------
Last Update Date | 07/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2621 5TH AVE
-----------------------------------------------------
City | SCOTTSBLUFF
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69361-1745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-635-3700
-----------------------------------------------------
Fax | 308-635-3709
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2621 5TH AVE
-----------------------------------------------------
City | SCOTTSBLUFF
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69361-1745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-635-3700
-----------------------------------------------------
Fax | 308-635-3709
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER/OWNER
-----------------------------------------------------
Name | MR. CASEY JOSEPH BRADSHAW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 308-635-3700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 10561404
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------