=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437139672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOTECHS O & P
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2006
-----------------------------------------------------
Last Update Date | 06/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3811 CENTRAL AVE SUITE F
-----------------------------------------------------
City | KEARNEY
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68847-8173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-865-6105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3811 CENTRAL AVE SUITE F
-----------------------------------------------------
City | KEARNEY
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68847-8173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-865-6105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TIMM WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 308-865-6060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------