=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619749884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CPO SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2023
-----------------------------------------------------
Last Update Date | 10/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 VILLAGE GREEN DRIVE SUITE 205
-----------------------------------------------------
City | LINCOLNSHIRE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-603-8854
-----------------------------------------------------
Fax | 847-238-3096
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 741 W MAIN ST
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61606-1953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-285-7752
-----------------------------------------------------
Fax | 309-285-7752
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER OF REVENUE CYCLE MANAGEMENT
-----------------------------------------------------
Name | KENDRA F MICKELSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-285-7752
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------